Otolaryngology Privileges.pdf

Delineation Of Privileges

Otolaryngology Privileges

Provider Name:

Privilege Requested

Deferred

Approved

Page 1 Printed on Wednesday, December 10, 2014

OTOLARYNGOLOGY PRIVILEGES Criteria - New Applicants: Board Certification or qualified for certification by the American Board of Otolaryngology. Criteria - Current Staff Members Only: Successful completion of an ACGME or AOA approved training program; OR demonstrated acceptable practice in the privileges being requested. Proctoring Requirements: A minimum of four (4) cases, in accordance with the Medical Staff Proctoring Protocol. Current Competence: Evidence of the successful performance, as primary surgeon, of at least four (4) Category 1 procedures every 2 years.

GENERAL PRIVILEGES:

Admit patients

___ ___ ___

Consultation Only Privileges

___ ___ ___

Surgical Assist ONLY

___ ___ ___

Sedation Analgesia: Criteria: Requires successful completion of the Sedation Assessment Test. Additional criteria effective April 1, 2015: a) Evidence of current ACLS and/or PALS certification from the American Heart Association; AND b) Evidence of completion of an Airway Management Course

___ ___ ___

a) Adult Sedation

___ ___ ___

b) Pediatric Sedation (17 years and under)

___ ___ ___

Local Block Anesthesia

___ ___ ___

Regional Block anesthesia

___ ___ ___

CATEGORY 1 - OTOLARYNGOLOGY PRIVILEGES Includes the management and coordination of care, treatment and services, including: Medical History and Physical examinations; consultations and prescribing medication in accordance with DEA certificate.

___ ___ ___

HEAD AND NECK



Provider Name:

Privilege Requested

Deferred

Approved


Lip shave

___ ___ ___

Wedge resection

___ ___ ___

Neck - I & D abscess

___ ___ ___

Excision skin lesions

___ ___ ___

Laryngoscopy

___ ___ ___

Esophagoscopy:

___ ___ ___

a) Diagnostic

___ ___ ___

b) With foreign body removal

___ ___ ___

c) With structure dilation

___ ___ ___

Bronchoscopy - diagnostic

___ ___ ___

Adenoidectomy

___ ___ ___

Tonsillectomy

___ ___ ___

Tracheotomy

___ ___ ___

Submaxillary gland excision

___ ___ ___

Lateral rhinotomy

___ ___ ___

Abbe-Estlander Flap

___ ___ ___

Cervical node biopsy

___ ___ ___

Scalene node biopsy

___ ___ ___

Exploration laryngeal fractures

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Exploration recurrent laryngeal nerves

___ ___ ___

Arytenoidectomy

___ ___ ___

Thyroidectomy

___ ___ ___

Parathyroidectomy

___ ___ ___

Tongue Base Suspension

___ ___ ___

Genioglossus Advancement

___ ___ ___

Hyoid Myotomy and Suspension

___ ___ ___

Uvulopalatopharyngoplasty

___ ___ ___

Major vessel ligation

___ ___ ___

Branchiogenic cysts

___ ___ ___

Thyroglossal cysts

___ ___ ___

Dermoids

___ ___ ___

Laryngoplasty

___ ___ ___

Tracheoplasty

___ ___ ___

Bronchoscopy - with foreign body removal

___ ___ ___

Bronchoscopy - with stricture dilation

___ ___ ___

Superficial parotidectomy with facial nerve dissection

___ ___ ___

Total parotidectomy with facial nerve dissection

___ ___ ___

Radical parotidectomy with or without nerve graft

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Partial maxillectomy

___ ___ ___

Total maxillectomy

___ ___ ___

Radical maxillectomy with orbital extenteration

___ ___ ___

Excision nasopharyngeal tumor

___ ___ ___

Partial glossectomy

___ ___ ___

Partial mandibulectomy

___ ___ ___

Composite resection - primary and tumor with RND

___ ___ ___

Radical neck dissection

___ ___ ___

Extended radical neck dissection (transternal mediastinal dissection)

___ ___ ___

Subtotal laryngectomy

___ ___ ___

Thyrotomy (laryngofissure)

___ ___ ___

Supraglottic laryngectomy

___ ___ ___

Hemilaryngectomy

___ ___ ___

Total laryngectomy with neck dissection

___ ___ ___

Cervical esophagectomy with neck dissection

___ ___ ___

Tracheal resection with repair

___ ___ ___

Infratemporal fossa surgery

___ ___ ___

Hypoglossal facial anastomosis

___ ___ ___

Laser Privileges:

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


a) C02 Laser

___ ___ ___

b) KTP Laser

___ ___ ___

c) Argon Laser

___ ___ ___

d) YAG Laser

___ ___ ___

Tracheo-Esophageal Puncture (TEP)

___ ___ ___

Microlaryngoscopy with Vocal Cord Injection

___ ___ ___

Thyroplasty Type 1

___ ___ ___

Temporal Artery Biopsy

___ ___ ___

Orbital Decompression

___ ___ ___

Endoscopic Repair of Zenkers Diverticulum

___ ___ ___

Open Repair of Zenkers Diverticulum

___ ___ ___

OTOLOGY

Myringotomy

___ ___ ___

Myringoplasty

___ ___ ___

Tympanoplasty with/without ossicular reconstruction

___ ___ ___

Tympanoplasty with mastoidectomy with/without reconstruction

___ ___ ___

Tympanostomy with PE Tube Placement

___ ___ ___

Mastoidectomy

___ ___ ___

Stapedectomy

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Stapes mobilization

___ ___ ___

Tympanic neurectomy

___ ___ ___

Labyrinthectomy

___ ___ ___

Excision tumor of ear and mastoid

___ ___ ___

Partial temporal bone resection

___ ___ ___

Radical temporal bone resection

___ ___ ___

Endolymphatic sac operations

___ ___ ___

Bone anchored hearing appliance

___ ___ ___

Ossicular Reconstruction

___ ___ ___

PLASTIC AND RECONSTRUCTION

Split thickness skin graft

___ ___ ___

Full thickness skin graft

___ ___ ___

Composite graft

___ ___ ___

Dermal graft

___ ___ ___

Scar revision

___ ___ ___

Reconstruction of external ear

___ ___ ___

Otoplasty

___ ___ ___

Rhinoplasty

___ ___ ___

Septorhinoplasty

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Rhytidectomy

___ ___ ___

Blepharoplasty

___ ___ ___

Reduction facial fractures:

___ ___ ___

a) Frontal

___ ___ ___

b) Nasal

___ ___ ___

c) Maxilla

___ ___ ___

d) Malar

___ ___ ___

e) Malar with orbital floor

___ ___ ___

f) Orbital blowout

___ ___ ___

g) Mandibular - closed

___ ___ ___

h) Mandibular - open

___ ___ ___

Implants

___ ___ ___

Fascial sling procedures

___ ___ ___

Condylectomy

___ ___ ___

Dacryocystorhinostomy

___ ___ ___

Regional myocutaneous flaps

___ ___ ___

Bone grafts

___ ___ ___

Liposuction

___ ___ ___

Prognathism correction

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Retrognathism correction

___ ___ ___

NASAL/SINUS

Nasal polypectomy

___ ___ ___

Submucous resection

___ ___ ___

Nasal septoplasty

___ ___ ___

Turbinectomy

___ ___ ___

Antrotomy

___ ___ ___

Caldwell Luc

___ ___ ___

Oroantral fistula repair

___ ___ ___

Choanal atresia repair

___ ___ ___

Transantral ligation of vessels

___ ___ ___

Transorbital Ligation of Vessels

___ ___ ___

Vidian neurectomy

___ ___ ___

Intranasal ethmoidectomy

___ ___ ___

External ethmoidectomy

___ ___ ___

Frontoethmoidectomy

___ ___ ___

Frontal sinus trephine

___ ___ ___

Osteoplastic frontal sinusectomy

___ ___ ___

Frontal sinus ablation

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


Nasal endoscopy, diagnostic

___ ___ ___

Endoscopic Sinus Surgery

___ ___ ___

Approach for Hypophysectomy

___ ___ ___

CATEGORY 2 ADVANCED OTOLARYNGOLOGY PRIVILEGES Criteria: Applicants must meet the criteria outlined for Category 1 Otolaryngology privileges; AND provide documentation of ability to perform the procedures requested, via certification by a Training Director regarding experience and demonstrated competence. Proctoring Requirements: Of the four (4) required proctoring cases, two (2) must be from the Category 2 Advanced privilege section, if Category 2 privileges are requested. Current Competence Requirements: Evidence of the successful performance, as primary surgeon, of at least three (3) Category 2 procedures every 2 years.

CATEGORY 2 Advanced Otolaryngology Privileges:

Cleft lip repair

___ ___ ___

Cleft palate repair

___ ___ ___

Cochlear implant

___ ___ ___

Major vessel grafting

___ ___ ___

Resection acoustic neuroma translabyrinthine (transmastoid)

___ ___ ___

Middle cranial fossa surgery

___ ___ ___

VIII nerve section via middle fossa

___ ___ ___

Retrolabyrinthine nerve section

___ ___ ___

T.M.J. exploration

___ ___ ___



Provider Name:

Privilege Requested

Deferred

Approved


CATEGORY 2 - ROBOTIC ASSISTED SURGERIES: Criteria: Applicants must be Board Certified or eligible for certification by the American Board of Otolaryngology. Must meet the criteria outlined for Category 1. Must provide documentation of course attendance and completion of the Training Workshop for the da Vinci system as it applies to ENT procedures; and meet one of the following: Route "1" Criteria: Requires previous practical experience via an accredited residency or fellowship program with documented clinical experience of a minimum of twenty (20) robotic assisted procedures, with at least ten (10) as the primary surgeon. Route "1" Proctoring Requirements: At least the first three (3) cases as the primary surgeon, proctored by a surgeon who has performed a minimum of ten (10) robotic procedures. Competency Requirements: Performance of at least five (5) robotic procedures per year as primary surgeon to maintain robotic privileges. Physicians who fail to meet the competency requirements will be required to undergo proctoring of at least three (3) cases. Route "2" Criteria: Completion of an approved residency or fellowship program in the surgical specialty. Route "2" Proctoring Requirements: At least the first five (5) cases as the primary surgeon, proctored by two different surgeons who have performed a minimum of ten (10) robotic procedures. Competency Requirements: Performance of at least five (5) robotic procedures per year as primary surgeon to maintain robotic privileges. Physicians who fail to meet the competency requirements will be required to undergo proctoring of at least five (5) cases.

CATEGORY 2 - ROBOTIC ASSISTED SURGERIES

Radical Tonsillectomy

___ ___ ___

Supraglottic laryngectomy (includes resection of tumors of the pharynx and the larynx)

___ ___ ___

Base of tongue cancer resection

___ ___ ___

Sleep Apnea

___ ___ ___

Revised: 04/23/10, 10/28/10, 5/26/11; 01/26/12; 05/23/13; 5/22/14; 10/30/2014



Provider Name:

Privilege Requested

Deferred

Approved


ACKNOWLEDGEMENT OF THE PRACTITIONER: I have requested only those privileges for which my education, training, current experience and demonstrated performance I am qualified to perform, and that I wish to exercise at Huntington Hospital, and I understand that: a) in exercising my clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation; b) any restriction on the clinical privileges granted to me is waived in an emergency situation and in such a situation my actions are governed by the applicable section of the Medical Staff Bylaws or related documents. Signature of Applicant: ___________________________________ Date:___________________________

DEPARTMENT CHAIR RECOMMENDATIONS I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and recommend action on the privileges as noted above. Applicant may perform privileges and procedures as indicated: ______ YES ______ NO Exceptions/Limitations (Please Specify): ________________________________________________________________

APPROVALS:

Robotic Medical Director: ___________________________________ Date: __________ Section Chair: _____________________________________________ Date: __________ Department Chair: _________________________________________ Date: __________

Credential Committee Date: __________

Medical Executive Committee Date: __________

Board of Directors Approved on: __________

Otolaryngology Privileges.pdf

Documents

Transcript of Otolaryngology Privileges.pdf