Download family medicine - Fairview Health Services

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Fairview Health Services
FAMILY 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)
Fairview Maple Grove Medical Center
(Ambulatory Care Center) 1, 2
I need to the following Fairview Entity Box on Privilege Form
Individual Fairview hospital(s)
University of Minnesota Medical Center, Fairview (UMMC)
Fairview Maple Grove Ambulatory Surgery Center1
Fairview Hospital-Based Clinic
Fairview Maple Grove Ambulatory Surgery Center (MGASC)
(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.
THRESHOLD CRITERIA TO REQUEST PRIVILEGES
Must meet one (1) of the following paths:
Path I
Path II
● Family Medicine Residency
● Successful completion prior to 1978 of a minimum of one year of an ACGME or AOA approved Family Medicine
residency program, or the international equivalent in the specialty of Family Medicine
● Family Medicine board
● Family Medicine board certification by American Board of Family Medicine
certification by American
● Practice fulltime family medicine since certification
Board of Family Medicine
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
**NOTE: Physician must document management of at least 100 family medicine patients during the past 24
months. Each individual core also has a specified number of patients required for the core. Individual core
patient numbers must be met if requesting the core and the core patients may be counted as part of the overall
100 total patients managed in the past 24 months.
Special
Request
Privileges
Must provide one (1) of the following - training or cases must have been completed within the past 24 months:
● Letter from a residency or fellowship program verifying training specific to the procedure;
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.
Z:\Privilege Forms\Family Medicine.doc
12/11; 8/12;3/13;4/13;8/13;3/14
Approved: 3/4/98; Revision approved: 6/13/01; 3/02; 4/02 (Ridges); 6/03; 3/06; 3/08; 1/09; 6/09 new format only; 9/09; 2/10; 8/11; 9/11 Bylaws change;
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Fairview Ambulatory Entity Code
FV Clinics = Fairview Free-standing Ambulatory Clinics
MGASC = Fairview Maple Grove Ambulatory Surgery Center
Fairview Hospital Entity Codes
UMMC - University of Minnesota Medical Center, Fairview
FSH - Fairview Southdale Hospital
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
ADULT
Threshold
Criteria
Core
Privileges
Must meet Threshold Criteria as listed on page 1
Cross out privileges you do not
Check Entity(ies) Where Privileges Requested
Competency
perform
Measures/
Privileges include admission, evaluation,
Hospital Entities
Ambulatory
Required #
diagnosis and treatment of patients > 18
Cases in Past
years of age, including medical care of
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
the elderly. Privileges also include, but
are not limited to:
24 adult
● Perform history and physical exam
medicine
● Central line placement
patients
● Lumbar puncture
(inpatient,
● Ability to assist in surgery
ambulatory &/or
consultative)
● Suturing
● Incision and drainage of abscess
● Removal of non-penetrating corneal foreign body
● Simple skin biopsy or excision
● Medical care of patients requiring intensive care observation
● Care of the uncomplicated myocardial infarction or rule-out MI,
● Closed fractures, uncomplicated dislocation
● Preop care of surgical patients
thrombolytics for acute MI, EKG interpretation
● Treatment of alcoholism and other types of chemical dependency
● Postop medical care of surgical patients
● Endometrial biopsy
● Form a differential diagnosis, order appropriate lab work, design
treatment and provide necessary and appropriate follow up care
● Large joint injection/aspiration
● Removal of moles and toenails
● I & D Bartholin cyst without marsupialization
● Punch biopsy of skin
● IUD placement
Competency
Check Entity(ies) Where Privileges Requested
Special Request Privileges
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
AF
AF
AF
AF
AF
AF
N/A
Acupuncture- You may also obtain referenced additional
privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
AF
AF
AF
AF
Appendectomy
5
N/A
N/A
N/A
Breast Biopsy
5
N/A
N/A
N/A
Cardiac Stress Testing
5
Chest Tube Placement
5
NOTE: You may also obtain referenced additional privilege
form (AF) at www.fairview.org/credentialing/PrivilegeForms
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
N/A
N/A
Sleep Medicine - You may also obtain referenced
additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
Adult Family Medicine Special Request Privileges continued on next page
AF
AF
AF
AF
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Competency
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
AF
AF
N/A
AF
AF
AF
AF
Check Entity(ies) Where Privileges Requested
Hospital Entities
Ambulatory
Colonoscopy and Snare Polypectomy - You may also
obtain referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
N/A
Flexible Sigmoidoscopy with or without Biopsy
5
Herniorrhaphy
5
Paracentesis
5
Thoracentesis
5
Tonsil & Adenoidectomy
5
N/A
N/A
5
*
**
Ventilator Management
*UMMC-with consultation as identified in Rules & Regs
**FSH–see Rules & Regulations for policy on ventilator management
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Allergy Skin Testing
5
Fine Needle Aspiration of Breast Cysts
5
Botox Injection - Cosmetic
5
Laser for Aesthetic Procedures - hair
removal/reduction, wrinkle reduction, acne, leg veins,
vascular lesions, pigmentation, tattoo removal, skin
rejuvenation, vascular and pigmented lesions, sun damage.
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
N/A
N/A
N/A
N/A
Microdermabrasion Particle Skin Resurfacing,
Cosmeceutical Skincare Products and Chemical
Peels
5
N/A
N/A
N/A
N/A
Sclerotherapy of Reticular & Spider Veins
5
Vasectomy
5
AF
AF
AF
AF
N/A
N/A
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
Colposcopy with/without Cervical Biopsy
5
Diagnostic Gyn D&C
5
LEEP (loop electrosurgical excision procedure of the
cervix uteri)
5
Instrumentation D&C (1st trimester and post partum
D&C)
5
Tubal Ligation – Post Partum
5
N/A
Tubal Ligation – Laparoscopic
5
N/A
Prenatal Management
Initial Appointment or First Request: Documentation
of completion of a Family Medicine training program
within the past 24 months or documentation of
management of 10 prenatal patients within the past
24 months.
See criteria
AF
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
5
Adult Family Medicine Special Request Privileges continued on next page
N/A
Reappointment: 10 cases in 24 months
Vacuum Curretage
AF
N/A
N/A
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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
Initial Appointment or First Request AND Reappointment Must meet one (1) of the following:
1) Successful completion within the past 24 months of an
ACGME or AOA approved residency training program that
included training specific to point of care ultrasound.
Documentation must include a letter from the Residency
Director, Director of Emergency Ultrasound or
Department Chair documenting training and use of point
of care ultrasound.
See criteria
listed
OR
N/A
2) Documentation of successful completion of a training
course specific to point of care ultrasound within the past
24 months. Training course must be a minimum of 8
hours and include the physics of ultrasound and hands on
training.
OR
3) If training (#1 or 2 above) was completed longer than 24
months ago, must document successful completion of a
minimum of 50 total point of care ultrasound exams in
the past 24 months (by requesting this privilege, I attest
to completing appropriate training course in point of
care ultrasound).
Clinical Bone Densitometry - You may also obtain
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
AF
AF
AF
AF
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OBSTETRICS
Threshold
Criteria
Core
Privileges
Must meet Threshold Criteria as listed on page 1
Cross out privileges you do not
Competency
perform
Measures/
Privileges include admission,
Required #
evaluation, diagnosis and treatment,
Cases in Past 24
including the ability to perform normal
Months
spontaneous vaginal delivery of the
term vertex presentation, ante-partum
and post-partum care, premature
See below
labor at > or = 36 weeks, preterm
labor at 24-36 weeks.
Privileges also include, but are not limited to:
● Perform history and physical exam
● Management of prenatal care
Check Entity(ies) Where Privileges Requested
Hospital Entities
UMMC
FSH
FRH
FNH
Ambulatory
FLH
FV Clinics
● Administration of pitocin
● Repair of minor vaginal and cervical lacerations
● OB ultrasound to evaluate fetal position
Competency Measures/Required # of Cases in Past 24 Months - Must meet one (1) of the following:
1) 24 deliveries and/or primary management of labor
OR
2) If you CURRENTLY HOLD Obstetrics core privileges at a Fairview hospital and have greater than 12 deliveries and/or
primary management of labor in the past 24 months, but less than 24 cases - successful completion of ALSO Course
(Advanced Life Support in Obstetrics) taken within the past 24 months (submit case list and ALSO course certificate).
In this situation, the next 5 cases will be subject to review after the granting of privileges.
Competency
Measures/
Required #
Cases in Past 24
Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
AF
AF
AF
N/A
Cesarean Section
5
NA
N/A
N/A
N/A
N/A
Low Forceps
5
N/A
Multiple Gestational Delivery
5
N/A
Special Request Privileges
NOTE: You may also obtain referenced additional
privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
Check Entity(ies) Where Privileges Requested
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
Repair of 3rd Degree Laceration/Episiotomy (a tear
N/A
that goes through the rectal sphincter but does not get
into the rectal lumen or mucosa)
Initial Appointment or First Request:
Documentation of training in procedure in a residency
program completed within the past 24 months.
Documentation may be in the form of a letter from the
program director.
OR
If training program was completed longer than 24 months
ago, must document completion of 3 procedures within
past 24 months. If 3 procedures have not been performed,
privileges may be granted provisionally and cases
proctored until the number is reached (submit request for
proctoring).
Vacuum Extractor (if number performed is less than 5 in the
past 24 months, may meet requirement by submitting certificate
from a skills-based course specific to vacuum extractor completed
within past 24 months)
Obstetrical Ultrasound (for other than fetal placement)
Management of Ectopic Pregnancy
Initial Appointment or First Request:
Documentation of completion of 50 C-sections and 30
laparoscopy procedures AND recommendation from a board
certified OB/GYN who has proctored cases within the past
24 months. Case documentation can be cumulative and
include cases prior to the last 24 months.
Reappointment:
Documentation of management of 5 cases of management
Initial
Appointment/
First Request =
See specific
requirements
Reappointment =
No
documentation
required
5
N/A
5
Initial
Appointment/
First Request
/Reappointment
= See specific
requirements
N/A
N/A
N/A
N/A
N/A
of ectopic pregnancy or documentation of 10 laparoscopy
procedures in the past 24months or recommendation from
a proctoring physician.
PAGE 6 OF 7
PEDIATRICS
Threshold
Criteria
Must meet Threshold Criteria as listed on page 1
Core
Privileges
Cross out privileges you do not
perform
Privileges include admission, evaluation,
diagnosis and treatment of general
pediatric patient 18 years of age or
under. This includes the care of the
normal newborn, neonatal circumcision,
peripheral arterial puncture, start
peripheral IV, pediatric circumcision (up
to 6 months) and lumbar puncture
(excluding newborns). Privileges also
include, but are not limited to:
● Perform history and physical exam
● Ability to assist in surgery
● Suturing
● Incision and drainage of abscess
● Simple skin biopsy or excision
Competency
Measures/
Required #
Cases in Past
24 Months
Check Entity(ies) Where Privileges Requested
Hospital Entities
UMMC
FSH
FRH
FNH
Ambulatory
FLH
FV Clinics
24 pediatric
patients
(inpatient,
ambulatory &/or
consultative)
●
●
●
●
Removal of non-penetrating corneal foreign body
Closed fractures, uncomplicated dislocation
Preop care of surgical patients
Postop medical care of surgical patients
Competency
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
AF
AF
AF
N/A
Appendectomy
5
N/A
N/A
N/A
Breast Biopsy
5
N/A
N/A
N/A
Chest Tube Placement
5
Herniorrhaphy
5
N/A
N/A
N/A
Pediatric Circumcision (> 6 months)
5
N/A
N/A
N/A
Tonsil & Adenoidectomy
5
N/A
N/A
N/A
Special Request Privileges
NOTE: You may also obtain referenced additional privilege
form (AF) at www.fairview.org/credentialing/PrivilegeForms
Check Entity(ies) Where Privileges Requested
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
N/A
N/A
N/A
N/A
PAGE 7 OF 7
LEVEL II NURSERY
Threshold
Criteria
Core
Privileges
Must meet Threshold Criteria as listed on page 1
Cross out privileges you do not
perform
Privileges include admission, evaluation,
diagnosis and treatment of newborns
admitted to the Level II Nursery,
including perform history and physical
exam.
Competency
Measures/
Required #
Cases in Past
24 Months
Check Entity(ies) Where Privileges Requested
Hospital Entities
UMMC
FSH
FRH
10 Level II
nursery
patients
Ambulatory
FNH
FLH
FV Clinics
N/A
N/A
N/A
Competency
Measures/
Required #
Cases in Past
24 Months
UMMC
FSH
FRH
FNH
FLH
FV Clinics
referenced additional privilege form (AF) at
www.fairview.org/credentialing/PrivilegeForms
AF
AF
AF
AF
N/A
N/A
N/A
Chest Tube Placement
5
N/A
N/A
N/A
Newborn Lumbar Puncture
5
N/A
N/A
N/A
Suprapubic Bladder Tap
5
N/A
N/A
N/A
Umbilical Venous/Artery Catheterization
5
N/A
N/A
N/A
Special Request Privileges
NOTE: You may also obtain referenced additional privilege
form (AF) at www.fairview.org/credentialing/PrivilegeForms
Check Entity(ies) Where Privileges Requested
Hospital Entities
Ambulatory
Moderate and Deep Sedation - You may also obtain
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 FAMILY 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 the care of a minimum
of 100 primary care patients during the past 24 months. I also attest that I have completed the minimum number of
patients/procedures listed for each of the requested core(s) within the past 24 months. I understand the core number
may be included in the 100 patient total.
____Adult - at least 24 adult patients
____Obstetrics - at least 24 deliveries
____Pediatric - at least 24 pediatric patients
____Level II Nursery - at least 10 Level II nursery patients
*NOTE: Total patients in past 24 months must be at least 100 and may be a combination of inpatient and ambulatory.
Individual numbers for inpatient cores must be met but can be included in the 100 total.
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