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Fairview Health Services
INTERNAL MEDICINE
Delineation of Privileges
Applicant’s Name (please print):
Must be an MD/DO and have completed Threshold Criteria listed in the individual privilege sections. Completion of an ACGME or AOA
approved residency and fellowship program (as applicable) is required. Current board certification by an American Board of Medical
Specialties (ABMS) approved board or AOA/RCPSC approved board, or admissible for examination for certification and certification
must be achieved within the time frame mandated by the appropriate board or within five (5) years after completion of residency
training for those specialties where time frames are not mandated.
CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES
I Want to Work at the Following Fairview Entity
Inpatient/hospital(s)
I need to the following Fairview Entity Box on Privilege Form
Individual Fairview hospital(s)
Fairview Maple Grove Medical Center
(Ambulatory Care Center) 1, 2
Fairview Maple Grove Ambulatory Surgery Center1
University of Minnesota Medical Center, Fairview (UMMC)
Fairview Maple Grove Ambulatory Surgery Center (MGASC)
Fairview Hospital-Based Clinic
(such as UMMC Clinics, Fairview Ridges Specialty Clinic for
Children, Fairview Southdale Oncology Clinic, Fairview
Southdale Hospital Breast Center)1, 3
Individual Fairview hospital where clinic is affiliated
Fairview Free-Standing Ambulatory Clinics1
Fairview Group Practice Ambulatory Clinics (FV Clinics)
1
Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to
those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not
otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel.
2
Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites.
3
Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with
procedures available at the clinic.
COMPETENCY MEASURES DOCUMENTATION REQUIREMENTS
I am a NEW APPLICANT to Fairview or Requesting Additional Privilege(s) NOT CURRENTLY HELD at a Fairview entity - Submit
documentation listed below for requested privileges.
Core
● Out of Training Less Than 24 Months - Requirements may be met by verification of formal training program
Privileges
completion in past 24 months
● Out of Training Greater Than 24 Months - Documentation of cases required for Competency Measures may be
met by submitting the attached “Verification of Patient Management & Participation for Core Privileges
Special
Must provide one (1) of the following - training or cases must have been completed within the past 24 months:
Request
● Letter from a residency or fellowship program verifying training specific to the procedure;
Privileges
OR
● Letter or certificate from an additional training course specific to the procedure;
OR
● Documentation of specified number of cases assigned to each procedure performed (copies of operative
reports, chart notes, or a list of cases performed). Documentation must include date the procedure was performed,
type of procedure and where performed (e.g., name of hospital or other facility). Laser cases must also list the type of
laser used. Please delete all patient identifiers such as name or medical record number from documentation to protect
individual patient confidentiality.
I CURRENTLY HOLD the specific privilege(s) at a Fairview entity: Sign the attestation listed on the last page of this privilege form
attesting to the completion and satisfactory performance of the required number of cases for core and special request privileges as
noted by each privilege. NOTE: By signing the attestation, you do not need to provide additional documentation at this time;
however, Fairview will randomly audit applicants and, if selected, you will be required to provide the required documentation.
Erroneous information related to the attestation may result in immediate suspension of privileges and lead to an investigation that
may result in disciplinary action.
Q:Central-Metro-Shares\UMMC-Business\SHAREDIR\CREDENTIAILNG DEPT\Privilege Forms\Internal Medicine.doc
Approved: 3/4/98; Revised 12/12/01; 12/6/02 (SCPC subcomm); 1/7/03 (SCPC subcomm); 1/06; 11/06 (subcomm); 3/08; 5/08; 1/09; 6/09 new format only; 9/11 Bylaws change; 12/11; 8/12
PAGE 2 OF 4
Fairview Hospital Entity Codes
Fairview Ambulatory Entity Code
UMMC - University of Minnesota Medical Center, Fairview
FV Clinics = Fairview Free-standing Ambulatory Clinics
FSH - Fairview Southdale Hospital
MGASC = Fairview Maple Grove Ambulatory Surgery Center
FRH - Fairview Ridges Hospital
FNH - Fairview Northland Medical Center
FLH - Fairview Lakes Medical Center
Definitions/Abbreviations
Core Privileges - Privileges routinely taught in residency/fellowship programs
Special Request Privileges - Privileges not routinely taught in residency/fellowship programs; new technology or procedure; high
risk; or requires ongoing practice to maintain competency
N/A - Indicates privilege not available at the specific Fairview entity
AF - Indicates an additional form is required to request the privilege
INTERNAL MEDICINE
Threshold
Criteria
Core
Privileges
● Internal Medicine Residency
● Internal Medicine board certification by American Board of Internal Medicine
Check Entity(ies) Where Privileges Requested
Competency
Cross out privileges you do not
Measures/
perform
Hospital Entities
Ambulatory
Required #
Privileges include admission, evaluation,
Cases in Past
diagnosis and treatment, including
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
consultation, of patients presenting with
medical problems. Privileges also
100
include, but are not limited to:
(inpatient,
● Perform a history & physical exam
ambulatory &/or
● EKG interpretation
consultative)
● Lumbar puncture
● Flex sigmoidoscopy without biopsy
● Order appropriate lab work
● Thoracentesis
● Design treatment, provide necessary and appropriate follow-up care
● Paracentesis
● Spirometry
● Central venous catheter
● Arthrocentesis
● Arterial line placement
● Large joint injection
● Indirect laryngoscopy using light & mirror
● Minor suturing
● Bone marrow aspiration/biopsy
● Punch biopsy of the skin
● Arterial puncture for blood gases
● Removal of moles and toe nails
● Form a differential diagnosis
Competency
Check Entity(ies) Where Privileges Requested
Special Request Privileges
NOTE: You may also obtain referenced additional privilege
form (AF) at www.fairview.org/credentialing/PrivilegeForms
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
AF
AF
AF
AF
AF
AF
N/A
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
Cardiac Stress Testing
5
Elective Endotracheal Tube Placement
5
Flexible Sigmoidoscopy With Biopsy
5
Holter Interpretation
5
Indirect Laryngoscopy Using Fiberoptics
5
N/A
Percutaneous Liver Biopsy
5
N/A
Pleural Biopsy
5
N/A
N/A
N/A
Pulmonary Artery Catheterization (Swan-Ganz)
NOTE: No documentation necessary if you currently hold core
privileges in Critical Care Medicine at a Fairview Hospital
Temporary Venous Pacemaker Placement
N/A
5
5
N/A
N/A
Sleep Medicine - You may also obtain referenced
additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
Internal Medicine Special Request Privileges Continued on Next Page
AF
AF
AF
AF
AF
PAGE 3 OF 4
Competency
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
* UMMC - with consultation as identified in Rules & Regulations
**FSH – see Fairview Southdale Hospital’s Critical Care policy on
ventilator management
5
*
**
Cardioversion
5
N/A
Laser - By requesting laser privileges, I attest that I will only use
those lasers for which I have been trained and I will review laser
safety information at the Fairview entity prior to using a laser
5
Check Entity(ies) Where Privileges Requested
Hospital Entities
FRH
FNH
Ambulatory
FLH
FV Clinics
Ventilator Management
Laser for Vascular and Pigmented Lesions - select
patient age group:
___Pediatric
___Adolescent/Young Adult
___Adult
By requesting laser privileges, I attest that I will only use those lasers
for which I have been trained and I will review laser safety
information at the Fairview entity prior to using a laser
Initial Appointment or First Request:
Must meet all of the following:
1) Documentation of successful completion of a course or
training program of at least 4 months that includes
working with patient age group (selected above) on which
procedures will be performed
AND
N/A
N/A
Initial
Appointment/
First Request =
See specific
requirements
Reappointment = 5 cases
N/A
N/A
2) Documentation of successful completion of at least 5
procedures in the past 24 months
Colonoscopy and Snare Polypectomy - You may also
obtain referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
N/A
N/A
AF
AF
AF
AF
AF
AF
N/A
N/A
N/A
N/A
N/A
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
AF
Transplant Medicine - You may also obtain referenced
additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
Gastroscopy
Acupuncture - You may also obtain referenced additional
privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
5
AF
Allergy Skin Testing
5
Echo Interpretation
5
Chemotherapy
5
Clinical Bone Densitometry - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
Cystoscopy
5
Fine Needle Aspiration - Specify Organ:__________
5
Hemorrhoidectomy
5
Sports Medicine (Sports Medicine must comprise 50%+ of
practice to request these privileges) - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
Internal Medicine Special Request Privileges Continued on Next Page
PAGE 4 OF 4
Competency
Measures/
Required #
Cases in Past
24 Months
Check Entity(ies) Where Privileges Requested
Hospital Entities
UMMC
FSH
FRH
FNH
Ambulatory
FLH
FV Clinics
Point of Care Ultrasound for Procedures (Specify which
procedure(s) you are requesting:
Paracentesis _______
Thoracentesis_______
Vascular Access_______
Initial Appointment or First Request:
1. Documentation of successful completion of formal
training in an approved IM residency program
within the past 24 months where ultrasound for
procedures was part of training; OR
2.
Documentation of successful completion of a CME
accredited course on the use of ultrasound for the
procedures requested within the past 24 months.
CME must include hands-on experience; OR
3.
Documentation of use of ultrasound in procedures
by providing log book of including the number of
cases identified below in which ultrasound was
used. Procedures must have been provided within
the past 24 months.
Paracentesis = 5
Thoracentesis = 5
Vascular Access = 5
Reappointment: Must document the number of cases
identified in #3 above performed within the past 24 months
REQUIRED DOCUMENTATION, ATTESTATION AND SIGNATURE
□ I am a NEW APPLICANT to Fairview or Requesting Additional Privilege(s) NOT CURRENTLY HELD at a Fairview
entity - Submit documentation required for Competency Measures as listed on page 1.
□ I CURRENTLY HOLD the specific privilege(s) at a Fairview entity:
By my signature below on this privilege form, I
attest to the completion in the past 24 months of at least the required number of cases listed above for each
requested privilege(s) with acceptable results based on quality improvement activities and outcomes.
NOTE: By signing the attestation below, you do not need to provide additional documentation at this time; however, Fairview will randomly
audit applicants and, if selected, you will be required to provide the required documentation. Erroneous information related to the attestation
may result in immediate suspension of privileges and lead to an investigation that may result in disciplinary action.
I understand that by making these privilege requests, I am bound by the applicable bylaws or policies of the entity at
which the privileges are requested. I also attest that my professional liability insurance covers the privileges I have
requested.
_____________________________________________________
Signature
______________________
Date
PAGE 1 OF 1
Fairview Health Services
TRANSITIONAL SERVICES (SUBACUTE)
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW
Delineation of Privileges
University of Minnesota Medical Center, Fairview Transitional Services is a 43-bed inpatient subacute facility
located on the 5th floor of the Rehab Building on the Riverside campus. The program is a short stay facility but
holds a nursing home license that requires physicians to apply for specific privileges. Patients are admitted
from Fairview hospitals and stay an average of two weeks. The focus areas of the program include: complex
medical, orthopedic and physical rehabilitation. Some of the services offered the patients include: IV therapy
including but not limited to antibiotics, blood products, lipids, non monitored cardiovascular drugs, morphine
drips and epidural medications.
Privileges are limited to the subacute program and include admission, workup, diagnosis and treatment of patients 16
years of age and over. Also included is administration of anxiolytic or narcotic drugs for the relief of pain or anxiety during
the performance of specific procedures. It is the expectation that physicians respond in a timely manner to requests by
the charge nurse. Initial physician visit must occur within a time frame appropriate to the patient’s condition
but not to exceed 48 hours after admission.
UMMC
Check Entity Where Privileges Requested
Transitional Services Core:
Care of Complex Medical Patients: Privileges include assessment and management of complicated or multiple concurrent
medical conditions. Complex medical care includes, but is not limited to, management of patients with: unstable diabetes,
and diabetic management, general metabolic instability, complex pressure sores, vascular ulcer, non-monitored cardiac
conditions, patients awaiting transplants, complicated infections, AIDS/HIV, post surgical conditions, pulmonary conditions,
malignancies, post surgical wound management, and post transplant management. Methods of treatment include, but are
not limited to: enteric and parenteral feedings, pain management, IV therapy such as lipids, antibiotics, blood/blood
products, multiple indwelling tubes and IV lines, multiple wound treatments.
Care of Orthopedic Patients: Privileges include assessment and management of orthopedic patients with varying degrees
of complexity. Orthopedic care includes, but is not limited to, management of patients with: joint replacements, fractures,
injuries with multiple fractures, spine conditions, musculoskeletal disorders, amputation, and post surgical conditions, most
of which would require therapy, occupational therapy and other relevant services.
Care of Rehabilitation Patients: Privileges include assessment, management and supervision of rehabilitation of patients.
Rehabilitation care conditions include, but are not limited to, management of patients with: stroke, general deconditioning,
cardiac rehabilitation, and neurological conditions, which require physical therapy, occupational therapy, speech therapy
and other relevant services.
I understand that by making this request, I am bound by the applicable bylaws or policies of the entity at which the
privileges are requested. I also attest that my professional liability insurance covers the privileges I have requested.
Signature
Q:Central-Metro-Shares\UMMC-Business\SHAREDIR\CREDENTIAILNG DEPT\Privilege Forms\Transitional Services-Subacute.doc
Approved: September 16, 1997; Revised 02/02
Date
VERIFICATION OF PATIENT MANAGEMENT & PARTICIPATION
FOR INTERNAL MEDICINE CORE PRIVILEGES
This Section to be Completed by PHYSICIAN Applying for Privileges
Physician Name__________________________________ Initial Appointment___ Reappointment___
I am requesting the following core(s) privileges. I attest that I have managed and participated in or completed the
minimum number of patients/procedures listed for each of the requested core(s) within the past 24 months.
____Internal Medicine - 100 patients
This Section to be Completed by CLINIC
MANAGER OR PEER* Verifying Physician’s Patient Management &
Participation
*Must have current knowledge of physician’s practice
The above-referenced physician is applying for core privileges at a Fairview hospital or clinic. Please complete the
following questions to verify the physician has met the current clinical competency criteria for the core privileges being
requested. Thank you for your assistance.
1.
Within the past 24 months, has the above-referenced physician managed and participated in or completed the
above-noted required number of patients/procedures in the core(s) being requested (either inpatient, ambulatory
or consultative)? Yes____ No*____ *If no, please explain below in the Additional Comments area.
2.
Do you have any concerns about this physician performing the requested privileges?
Yes*____ No____
*If yes, please explain below in the Additional Comments area.
Additional Comments: _______________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Name (please print)
Title
Phone Number
_________________________________________________________________________________________________
Signature
Date
Clinic Name and Address_____________________________________________________________________________
CLINIC MANAGER OR PEER - RETURN FORM WITHIN 1 WEEK DIRECTLY TO:
Fairview System Credentialing
Initial Appointments - Fax (612) 672-4123
Reappointments - Fax (612) 672-7733
If you have questions, please contact the Fairview System Credentialing Office at (612) 672-7700