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PAGE 1 OF 4 Fairview Health Services HEMATOLOGY/MEDICAL ONCOLOGY 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\Hematology-Medical Oncology.doc Approved: 3/07 (new format); 3/09; 6/09 new format; 9/11 Bylaws change; 8/12;3/14 PAGE 2 OF 4 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 GENERAL INTERNAL MEDICINE - request if current practice includes general internal medicine Threshold Criteria Core Privileges ● Internal Medicine Residency ● Internal Medicine board certification by American Board of Internal Medicine or Internal Medicine subspecialty board certification by the American Board of Internal Medicine Cross out privileges you do not perform Privileges include admission, evaluation, diagnosis and treatment, including consultation, of patients presenting with medical problems. Privileges also include, but are not limited to: ● Perform history & physical exam ● EKG interpretation ● ● ● ● ● ● Competency Measures/ Required # Cases in Past 24 Months Check Entity(ies) Where Privileges Requested Hospital Entities UMMC FSH FRH FNH Ambulatory FLH FV Clinics 100 (inpatient, ambulatory &/or consultative) Lumbar puncture Flex sigmoidoscopy without biopsy Thoracentesis Paracentesis Indirect laryngoscopy using light and mirror Central venous catheter ● ● ● ● Arterial line placement Bone marrow aspiration/biopsy Arterial puncture for blood gases Form a differential diagnosis, order appropriate lab work, design treatment, and to provide necessary and appropriate follow-up care GENERAL PEDIATRICS - request if current practice includes general pediatrics Threshold Criteria Core Privileges ● Pediatrics Residency ● Pediatrics board certification by American Board of Pediatrics or Pediatric subspecialty board certification by the American Board of Pediatrics 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 between the ages of birth and young adulthood 100 presenting with medical problems, (inpatient, including the treatment of major or ambulatory &/or complicated illnesses and the consultative) performance of procedures that do not carry a significant threat to life. Privileges also include, but are not limited to: ● Perform history & physical exam ● Incision and drainage of superficial abscesses ● Circumcision ● Tying off of skin tags ● Treatment of hyperbilirubinemia ● EKG interpretation ● Venipuncture ● Normal newborn care and nursery skills related to ● Lumbar puncture resuscitation including intubation, line placement and ● Laceration repair chest tube placement PAGE 3 OF 4 HEMATOLOGY/MEDICAL ONCOLOGY Threshold Criteria ● Hematology or Medical Oncology Fellowship ● Hematology or Medical Oncology subspecialty board certification by American Board of Internal Medicine or Pediatrics Cross out privileges you do not Check Entity(ies) Where Privileges Requested Competency Core perform Measures/ Privileges Privileges include admission, Hospital Entities Ambulatory Required # evaluation, diagnosis and treatment, Cases in Past 24 including consultation, of patients of Months UMMC FSH FRH FNH FLH FV Clinics all ages presenting with illnesses and disorders of the blood and bloodforming tissues or malignant tumors. 100 Privileges also include, but are not (inpatient, limited to: ambulatory &/or ● Perform history & physical exam consultative) ● Para- and thoracentesis ● Management of implanted ports ● Management and care of indwelling venous access catheters ● Bone marrow aspiration/biopsy ● Administration of chemotherapy and biological response modifiers through ● Therapeutic phlebotomy therapeutic routes 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 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A AF AF AF AF AF Hospital Entities Ambulatory Moderate and Deep Sedation - You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms Lymph Node Aspiration 5 Plasmapheresis 5 Therapeutic Thoracentesis 5 Therapeutic Paracentesis Bone Marrow Harvesting Initial Appointment or First Request (must be completed within past 24 months): Successful completion of the following may be documented through a letter from the Medical Director of Adult/Pediatric BMT: 1) Successful performance of bone marrow biopsy and bone marrow aspiration AND 2) Completion of training module through appropriate department at the University of Minnesota AND 3) Assisting in 5 bone marrow harvesting cases Bone Marrow Transplant 5 Initial Appointment/ First Request = See specific requirements Reappointment = Documentation required at time of initial appointment only 5 Clinical Bone Densitometry - You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms AF AF PAGE 4 OF 4 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 HEMATOLOGY/MEDICAL ONCOLOGY 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. ____Hematology/Medical Oncology - 100 patients ____General Internal Medicine - 100 patients ____General Pediatrics - 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