Read Group Health Cooperative of Puget Sound Hospital System text version

AMBULATORY CARE

Medical and Professional Staff Clinical Privilege Request Form Group Health Cooperative Facilities DIAGNOSTIC RADIOLOGY

Practitioner Name:

___________________________________

To request clinical privileges, the following minimum threshold criteria must be met: Initial Appointment Requirements for Core Privileges: Professional Degree: M.D. or D.O. Post-graduate Education and Previous Experience: Successful completion of an ACGME/AOA, or equivalent, approved residency training program in Radiology with fulfillment of, or qualification for, board certification within the requirements of the American Board of Radiology. The applicant must have been actively engaged in the practice of Radiology for not less than 12 months in the last three years. References: At least three letters of reference from practitioners who are board certified in the same or related specialty who will attest to the applicant's clinical competence. A third reference may be queried as needed. Reappointment Requirements for Core Privileges: Documentation of clinical activity within the scope of core privileges requested, and demonstrated competency with acceptable peer review/case review over the past 24 months without significant quality variation. ..................................................................................................................................................... A representative but not inclusive list of procedures and competencies are stated below. It is expected that other procedures and problems of similar complexity will fall within the identified Core and Special Request Privileges. Implicit in these privileges is the understanding that disorders without definitive diagnoses, persistent or progressive signs and symptoms, or requiring care beyond the scope of the holder's training will require further consultation. Core Privileges in Diagnostic Radiology: Interpretation of routine radiographs including routine examinations of the genitourinary tract, routine vascular studies, but not limited to peripheral venogram, arthrogram, and myelogram.

Please Note: Radiation Oncology privileges must be requested on the Radiation Oncology Privilege form.

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 1

Special Request Privileges in Diagnostic Radiology

Practitioner Name:

___________________________________

Applicant: Check box for requested privileges and attach required documentation Initial Criteria Reprivilege Criteria Chief's Signature/Date Specific Privilege

Moderate sedation ­ Check appropriate age category(s). 1. Current ACLS, ARLS and/or 1. Current ACLS, ARLS and/or Privilege Granted. PALS training (or evidence PALS training (or evidence of of currently being an currently being an instructor instructor of ACLS, ARLS of ACLS, ARLS and/or PALS Privilege Withheld. and/or PALS training). training). Reason: Letter from training program _________________ AND: chair or previous hospital _________________ Chief of Clinical Services documenting competency and 2. Successful completion of acceptable outcomes. If this the online SeDaTE course. is unavailable, a specific CME http://ghc.sedationelearning. program and preceptorship com may be developed in conjunction with the Service Line Chief and Chief of Anesthesiology.

Pediatrics (requires PALS)

2.

Adult (requires ACLS or ARLS)

AND: 3. Successful completion of the online SeDaTE course. http://ghc.sedationelearning.com Chief Signature/Date Percutaneous organ access procedures, such as biliary drainage and/or stone extraction, nephrostomy, abscess drainage, organ access, percutaneous transhepatic cholangiography. Interventional studies including the classes of vascular access (routine cerebral angiography, splenoportogram, venacavogram) and therapeutic interventions (arterial perfusion, transcatheter embolectomy or embolotherapy; IVC filter placement; angioplasty of iliac or femoral arteries, or renal arteries or veins). Arterial/venous thrombolysis, vein ablation procedures, venous access devices, endovascular stent graft placement. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes. Privilege Granted. Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes. Privilege Granted.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 2

Practitioner Name:

___________________________________

Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. In accordance with the Stereotactic Breast Biopsy Accreditation Program, applicant must: 1) be fully qualified as an interpreting physician under MQSA and have at least 3 hours of Category I CME in stereotactic breast biopsy; AND 2) have performed at least 12 stereotactic breast biopsies or at least 3 hands-on stereotactic breast biopsy procedures under a physician who is qualified to interpret mammography under MQSA and has performed at least 24 stereotactic breast biopsies. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes. Privilege Granted. Privilege Withheld. Reason: _________________ _________________

Imaging guided biopsies

Stereotactic biopsies of the breast

Chief Signature/Date In accordance with the Privilege Granted. Stereotactic Breast Biopsy Accreditation Program, Practitioner must: Privilege Withheld. 1) perform at least 12 stereotactic breast biopsies per Reason: _________________ year; _________________ AND 2) obtain at least 3 hours of Category I CME in stereotactic breast biopsy every three years; and AND 3) submit letter from Service Line Chief, or designee, verifying compliance with MQSA guidelines. Chief Signature/Date Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes.

Interventional neuroradiology including stent placement and therapeutic injections. Therapeutic facet, S1 pyriformis, nerve root blocks, Trigger point injections.

Privilege Granted.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date Transvenous liver biopsy Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes. Privilege Granted. Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 3

Practitioner Name:

___________________________________

1. In accordance with NRC Privilege Granted. (Nuclear Regulatory Commission) licensing guidelines, applicant must be board certified in either Privilege Withheld. Nuclear Medicine or Diagnostic Reason: Radiology or Therapeutic Radiology or Radiation Oncology _________________ _________________ or have had 80 hours of classroom and laboratory training and supervised clinical experience under the supervision of an authorized user at a medical institution that includes: 1) use of iodine-131 for diagnosis of thyroid function and the treatment of hyperthyroidism or cardiac dysfunction in 10 individuals, 2) use of iodine-131 for treatment of thyroid carcinoma in 3 individuals, and 3) SR-89 and other pharmaceuticals as approved by the NRC and the State of Washington.

Nuclear medicine - please 1. In accordance with NRC (Nuclear Regulatory Commission) check appropriate licensing guidelines, applicant category(s): must be board certified in Nuclear Medicine or Diagnostic Radiology Diagnostic (includes or Therapeutic Radiology or routine nuclear medicine studies, including injection Radiation Oncology or have had 80 hours of classroom and of radioisotopes) laboratory training and supervised clinical experience under the supervision of an authorized user Therapeutic at a medical institution that includes: 1) use of iodine-131 for diagnosis of thyroid function and the treatment of hyperthyroidism or cardiac dysfunction in 10 individuals, 2) use of iodine-131 for treatment of thyroid carcinoma in 3 individuals, and 3) SR-89 and other pharmaceuticals as approved by the NRC and the State of Washington. AND:

AND: 2. Documentation of an average of at least 5 CME hours per year 2. Documentation of an in Diagnostic and/or Therapeutic average of at least 5 CME hours over the last two years. per year in Diagnostic and/or Therapeutic since your last appointment.. Chief Signature/Date PET Scan 1. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. 1. Approval of the Service Line Chief or designee, based on demonstrated competency and acceptable outcomes. AND: Privilege Granted.

2. Documentation of an average of at least 5 CME hours AND: per year in PET scan interpretation since last 2. Documentation of an average appointment. of at least 5 CME hours per year in PET scan intrepretation over the last two years. CT Scan 1. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. AND: 2. Documentation of an average of at least 5 CME hours per year in CT scan intrepretation over the last two years. 1. Approval of the Service Line Chief or designee, based on demonstrated competency and acceptable outcomes. AND: 2. Documentation of an average of at least 5 CME hours per year in CT scan interpretation since last appointment.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date Privilege Granted.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 4

Practitioner Name: DXA Scan

___________________________________

1. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. 1. Approval of the Service Line Chief or designee, based on demonstrated competency and acceptable outcomes. AND: Privilege Granted.

2. Documentation of an average of at least 5 CME hours AND: per year in DXA scan interpretation or Certification by 2. Documentation of an average the International Society for of at least 5 CME hours per year Clinical Densitometry or it's equivalent, since last in DXA scan interpretation or appointment. Certification by the International Society for Clinical Densitometry or it's equivalent, over the last two years. Ultrasound 1. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. AND: 2. Documentation of an average of at least 5 CME hours per year in US intrepretation over the last two years. 1. Approval of the Service Line Chief or designee, based on demonstrated competency and acceptable outcomes. AND: 2. Documentation of an average of at least 5 CME hours per year in US scan interpretation since last appointment.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date Privilege Granted.

Privilege Withheld. Reason: _________________ _________________

Chief Signature/Date MRI interpretation 1. Letter from training program chair or previous Chief documenting competency and acceptable outcomes. If this is unavailable, a specific CME program and preceptorship may be developed in conjunction with the Service Line Chief. AND: 2. Documentation of an average of at least 5 CME hours per year in MRI interpretation over the last two years. Chief Signature/Date 1. Approval of the Service Line Chief, or designee, based on demonstrated competency and acceptable outcomes. Privilege Granted.

Privilege Withheld. Reason: AND: _________________ 2. Documentation of an average _________________ of at least 5 CME hours per year in MRI interpretation since last appointment.

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 5

Practitioner Name: Mammography

___________________________________

In accordance with the MQSA (Mammography Quality Standards Act) guidelines: 1) License to practice in a state; AND 2) board certificate in Diagnostic Radiology; AND 3) documents showing 40 CME hours in mammography; AND 4) documents showing initial experience in reading/interpretation of mammograms from 240 patients during a 6 month period (any such experience acquired after October 1, 1994 must be under the supervision of a qualified interpreting physician). Letter from Service Line Chief, or Privilege Granted. designee, verifying compliance with MQSA guidelines as follows: 1) documents showing continuing Privilege Withheld. experience in reading and Reason: interpreting mammograms from the examination of an average of _________________ _________________ at least 40 patients per month over 24 months, AND 2) documents showing an average of 5 CME credits (earned or taught) per year in mammography.

Chief Signature/Date

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 6

Diagnostic Radiology

Practitioner Name: Continuing Medical Education I attest that I have completed the required number of Continuing Medical Education (CME) credits required by the state of Washington to maintain licensure. Board Certification I am board certified by the Board of Expiration date Expiration date Expiration date I am not currently board certified Request for Privileges within GHC Facilities I request core privileges in Diagnostic Radiology I request special request privileges as checked on pages 2-6 I understand that in making the above request(s) I am bound by the applicable Bylaws, Rules and Regulations, and Policies of Group Health Cooperative. I hereby stipulate that I meet the threshold criteria for each request and have attached the required documentation.

Signature GHC Facility Location Date

___________________________________

.......................................................................................................... PLEASE COMPLETE FORM ABOVE THIS LINE .............................................................................................................

Endorsement by the Service Line Chief, or designee, of privilege requests: Yes No Conditional

(Conditional endorsement requires a formal plan for monitoring competency to be attached. Denial requires a statement for the rationale.)

Chief's signature Print name Endorsement by Credentialing and Privileging Committee: Yes No Chair's signature Reviewed and approved by the Board of Trustees on

Date

Date

(Date)

Diagnostic Radiology Privilege Request Form ­ Ambulatory Care

Last Revised: 4/2010

Page 7

Information

Group Health Cooperative of Puget Sound Hospital System

7 pages

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

623705


Notice: fwrite(): send of 201 bytes failed with errno=104 Connection reset by peer in /home/readbag.com/web/sphinxapi.php on line 531