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PAGE 1 OF 4 Fairview Health Services OTOLARYNGOLOGY 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 the Maple Grove Ambulatory Care Center in accordance with procedures available at this site. 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\Otolaryngology.doc Approved: 3/4/98; 2/07 (subcomm); 1/09; 3/09; 6/09 new format; 9/09; 9/10; 9/11 Bylaws Change;8/12;5/13 PAGE 2 OF 4 Fairview Ambulatory Entity Code Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FV Clinics = Fairview Free-standing Ambulatory Clinics FSH - Fairview Southdale Hospital MGASC = Fairview Maple Grove 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 OTOLARYNGOLOGY Threshold Criteria Core Privileges ● Otolaryngology residency ● Otolaryngology board certification by American Board of Otolaryngology Check Entity(ies) Where Privileges Requested Competency Cross out privileges you do not Measures/ perform Hospital Entities Ambulatory Required # Privileges include performance of Cases in Past 24 surgical and non-surgical procedures Months UMMC FSH FRH FNH FLH FV Clinics to patients of all ages (including related admission, consultation, and workup) presenting with illnesses, 100 injuries and disorders of the head and (inpatient, neck affecting the ears, facial ambulatory &/or skeleton, respiratory and upper consultative) alimentary systems. Privileges also include, but are not limited to perform history and physical exam, surgery involving the temporal bone, nasal and paranasal sinus, maxillofacial, reconstructive, thyroid, salivary glands, and lymphatic tissue of the head and neck, and endoscopic procedures. MAPLE GROVE AMBULATORY SURGERY CENTER Threshold Criteria Core Privileges ● Otolaryngology residency ● Otolaryngology board certification by American Board of Otolaryngology Competency Check Entity(ies) Where Privileges Requested Measures/ Cross out privileges you do not Required # perform Cases in Past 24 Maple Grove Ambulatory Surgery Center Privileges include admission, correct Months or treat various conditions, illness and disorders of the head and neck 100 affecting the ears, facial skeleton and √ box for MGASC respiratory and upper alimentary (inpatient, ambulatory &/or system. consultative) Privileges also include, but are not limited to: ●Endoscopy of the larynx, tracheobronchial tree, and esophagus to include biopsy, excision, revision and foreign body removal ●Exploration/debridement/repair/excision/biopsy/aspiration of soft tissue, skin or nodes of the head or neck ●Surgery of the frontal, ethmoid, sphenoid and maxillary sinuses and turbinates, including endoscopic sinus surgery septoplasty ●Otological surgery including myringotomy, myringoplasty, tympanoplasty, mastoidectomy, stapedectomy, tonsillectomy, adenoidectomy PAGE 3 OF 4 Special Request Privileges NOTE: You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms Competency Measures/ Required # Cases in Past 24 Months UMMC FSH FRH FNH FLH FV Clinics MGASC AF AF AF AF AF AF N/A N/A AF AF AF AF N/A N/A N/A N/A AF AF AF AF AF AF AF AF AF N/A N/A N/A N/A N/A Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory Moderate and Deep Sedation - You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms Computer Enhanced Surgical Device (Robotic Surgery)- You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms 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 Sleep Medicine - You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms Gamma Knife - You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms 5 Initial Appointment/ First Request = see specific requirements Reappointment = no documentation required N/A Blepharoplasty 5 N/A Chemical Facial Peels 5 N/A Face and Brow Lifts 5 N/A Rhytidoplasty 5 N/A Sentinel Node Biopsy Initial Appointment/First Request - If residency was completed prior to 2003, check privilege here and submit documentation of 5 cases performed in past 24 months. If residency was completed in 2003 or after, check privilege here but no documentation is required as this procedure is considered core. Facial Cosmetic Surgery: Otolaryngology Special Request Privileges continued on next page N/A PAGE 4 OF 4 Special Request Privileges NOTE: You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms Competency Measures/ Required # Cases in Past 24 Months Check Entity(ies) Where Privileges Requested Hospital Entities UMMC FSH FRH FNH Ambulatory FLH FV Clinics MGASC Inner Ear Surgery: Acoustic Neuroma 5 N/A N/A N/A Sub-Total Temporal Bone Resection 5 N/A N/A N/A Total Facial Nerve Decompression 5 Vestibular Nerve Section 5 Cochlear Implants 5 Auditory Brain Stem Implants (ABI) Initial Appointment or First Request: Must provide documentation of one (1) of the following options completed within the past 24 months: 1) Successful completion of a two (2) day training program which included completion of one (1) proctored procedure with a physician privileged in the procedure OR 2) Completion of at least two (2) ABI procedures within the past 24 months as primary operator N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Initial Appt/ First Request = See specific requirements Reappointment = Attendance at 2 cases within past 24 months (need not be primary operator) Microvascular Surgery: Fibula Osteomyocutaneous 5 N/A N/A N/A Radial Forearm Free Flaps 5 N/A N/A N/A Pediatric Surgery: Cystic Hygroma 5 N/A N/A Laryngotracheoplasty 5 N/A N/A Tracheoresection 5 N/A N/A Cleft Palate and Lip Repair 5 N/A Dental Implants 5 N/A Pharyngoplasty 5 N/A N/A Rehabilitative Surgery: Skull Base Surgery: Craniofacial Resection 5 N/A N/A N/A Hypophysectomy 5 N/A N/A N/A 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 OTOLARYNGOLOGY 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. ____Otolaryngology - 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