department of anesthesiology - university of michigan health system

ANESTHESIOLOGY AND PAIN MEDICINE CLINICAL PRIVILEGES

Name:

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Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.

Service Chief / Department Chair: Check the appropriate box for recommendation on this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.

Other Requirements

• Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficientspace, equipment, staffing, and other resources required to support the privilege.

• This document is focused on defining qualifications related to competency to exercise clinicalprivileges. The applicant must also adhere to any additional organizational, regulatory, oraccreditation requirements that the organization is obligated to meet.

QUALIFICATIONS FOR ANESTHESIOLOGY Initial Applicants - To be eligible to apply for privileges in anesthesiology, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in anesthesiology or graduate from a professional school or program generally recognized for its quality of education, per Michigan Medicine Medical Staff Appointment Policy.

AND

Current certification or board eligible (with achievement of certification within five years of completion of training) leading to certification in anesthesiology by the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology or UMHS approved international equivalent.

AND

Required Current Experience: Demonstrated current competence and experience with at least fifty (50) hospital anesthesiology cases, reflective of the scope of privileges requested, within the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.


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CORE PRIVILEGES – ANESTHESIOLOGY

Applicant: Requested Initial Requested Renewal

Service Chief/Chair: Recommended Not Recommended Administration of anesthesia, including general, regional, and local, and administration of all levels of sedation to patients ages two (2) and above or five (5) and above with an ASA status of three (3) or greater. Care includes pain relief and maintenance, or restoration, of a stable condition during and immediately following surgical, obstetrical, and diagnostic procedures. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be monitored for eight (8) scheduled shifts that are a representative mix of privileges granted. Methods may include direct observation, case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in anesthesiology, the reapplicant must meet the following criteria: Board Certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Current demonstrated competence and experience with at least one-hundred (100) hospital anesthesiology cases, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

QUALIFICATIONS FOR PEDIATRIC ANESTHESIOLOGY Initial Applicants - To be eligible to apply for privileges in pediatric anesthesiology, the initial applicant must meet the following criteria:

1. Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) orAmerican Osteopathic Association (AOA) accredited residency in anesthesiology, followed bysuccessful completion of an accredited fellowship in pediatric anesthesiology

AND

Current certification or board eligible (with achievement of certification within five years of completionof training) leading to certification in pediatric anesthesiology by the American Board ofAnesthesiology.

OR

2. UMHS approved international equivalent which includes advanced training in pediatric anesthesiologyequivalent to that gained from a pediatric anesthesiology fellowship


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Required Current Experience: Demonstrated current competence and experience with at least fifty (50) pediatric anesthesiology cases, reflective of the scope of privileges requested, within the past 12 months or successful completion of an ACGME- or AOA-accredited fellowship or the equivalency training within a UMHS approved international program within the past 12 months.

CORE PRIVILEGES – PEDIATRIC ANESTHESIOLOGY


Service Chief/Chair: Recommended Not Recommended Administration of anesthesia, including general, regional, and local, and administration of all levels of sedation to pediatric patients less than two (2) years of age or less than five (5) years of age with an ASA status of three (3) or greater. Includes evaluation of complex medical problems in infants and children when surgery is needed; planning and care before and after surgery; pain control, if needed after surgery; and anesthesia and sedation for procedures out of the operating room such as MRI, CT scan, and radiation therapy. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be monitored for eight (8) scheduled shifts that are a representative mix of privileges granted. Methods may include direct observation, case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in pediatric anesthesiology, the reapplicant must meet the following criteria: Board Certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Current demonstrated competence and experience with at least one-hundred (100) hospital pediatric anesthesiology cases, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

QUALIFICATIONS FOR PEDIATRIC CARDIAC ANESTHESIOLOGY Initial Applicants - To be eligible to apply for privileges in pediatric cardiac anesthesiology, the initial applicant must meet the following criteria:

As for pediatric anesthesiology followed by successful completion of a recognized fellowship in pediatric cardiac anesthesiology or the equivalent in experience.

AND


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Required Current Experience: Demonstrated current competence and experience with at least twenty-five (25) pediatric cardiac anesthesiology cases, reflective of the scope of privileges requested, within the past 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months or UMHS approved international equivalent.

CORE PRIVILEGES – PEDIATRIC CARDIAC ANESTHESIOLOGY


Service Chief/Chair: Recommended Not Recommended Administration of anesthesia, including general, regional, and local, and administration of all levels of sedation. Includes preoperative, intraoperative, and postoperative care of pediatric patients undergoing cardiac surgery and related invasive procedures. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be monitored for an initial ten (10) cases that are a representative mix of privileges granted. Methods may include direct observation, case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in pediatric cardiac anesthesiology, the reapplicant must meet the following criteria: Board Certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Current demonstrated competence and experience with at least fifty (50) hospital pediatric cardiac anesthesiology cases, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.


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QUALIFICATIONS FOR CRITICAL CARE

Initial Applicants - To be eligible to apply for privileges in critical care, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in Anesthesiology, Emergency Medicine, Surgery or Pulmonary Medicine and successful completion of an accredited fellowship in critical care medicine or UMHS approved international equivalent.

AND

Current subspecialty certification or board eligible (with achievement of certification within five years of completion of training) leading to subspecialty certification in critical care medicine by the relevant American Board of Medical Specialties, or the American Osteopathic Board or UMHS approved international equivalent.

AND

Required Current Experience: Demonstrated current competence and experience with inpatient care to at least thirty (30) patients in the critical care unit, reflective of the scope of privileges requested, during the past 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.

CORE PRIVILEGES – CRITICAL CARE


Service Chief/Chair: Recommended Not Recommended Admit, evaluate, diagnose, and provide treatment or consultative services for patients of all ages, with multiple organ dysfunction and in need of critical care for life threatening disorders. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be monitored for an initial five (5) patients that are a representative mix of privileges granted. Methods may include direct observation, case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in critical care, the reapplicant must meet the following criteria:

Board Certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND


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Current demonstrated competence and experience with at least sixty (60) patients, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

QUALIFICATIONS FOR PAIN MEDICINE Initial Applicants - To be eligible to apply for privileges in pain medicine, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council on Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in anesthesia followed by successful completion of an ACGME- or AOA-accredited fellowship in pain medicine of at least twelve (12) months duration or UMHS approved international equivalent.

AND

Current subspecialty certification or board eligible (with achievement of certification within five years of completion of training) leading to subspecialty certification in pain medicine by the American Board of Anesthesiology or UMHS approved international equivalent.

AND

Required Current Experience: Demonstrated current competence and experience with inpatient, outpatient, or consultative pain medicine services for at least twenty-five (25) patients, reflective of the scope of privileges requested, during the past 12 months, or successful completion of an accredited residency, or clinical fellowship within the past 12 months.

CORE PRIVILEGES – PAIN MEDICINE


Service Chief/Chair: Recommended Not Recommended

Please check one: Non-Invasive Interventional (includes non-invasive) Evaluate, diagnose, treat, and provide consultation to patients of all ages, with acute and chronic pain or pain requiring palliative care. Includes invasive pain medicine procedures beyond basic pain medicine. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in pain medicine include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills as applicable to the requested area(s) of practice.


Name:

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Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be monitored for an initial five (5) cases that are a representative mix of privileges granted. Methods may include direct observation, case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in pain medicine, the applicant must meet the following criteria:

Board certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Current demonstrated competence and experience with at least fifty (50) inpatient, outpatient, or consultative pain medicine services, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA) Non-Core Privileges are requested individually in addition to requesting the core. Each individual requesting Non-Core Privileges must meet the specific threshold criteria as applicable to the initial applicant or re-applicant.

BEDSIDE PERCUTANEOUS TRACHEOSTOMY (PDT)

Applicant: Requested Initial Requested Renewal Service Chief/Chair: Recommended Not Recommended Criteria: Successful completion of an accredited ACGME or AOA post graduate training program that included training in PDT or completion of a hands-on CME with at least five (5) procedures in a supervised setting (training).

Required Current Experience: Demonstrated current competence and experience with at least five (5) procedures in the past 12 months or completion of training in the past 12 months.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be proctored in person for a minimum of five (5) procedures.

Renewal of Privilege: Demonstrated current competence and experience with at least ten (10) procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

MINIMALLY INVASIVE LUMBAR DECOMPRESSION (MILD)

Applicant: Requested Initial Requested Renewal Service Chief/Chair: Recommended Not Recommended


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Criteria: Successful completion of an ACGME or AOA-accredited PGT program in pain medicine, neuroradiology, neurosurgery, or orthopedics that included training in image-guided percutaneous procedures involving the spinal region and completion of a hands-on percutaneous MILD cadaver course with certification. Annual training in radiation safety. Must qualify for and be granted fluoroscopy privileges.

Required Current Experience: Demonstrated current competence and experience with the performance of at least five (5) MILD procedures in the past 12 months or completion of training in the past 12 months.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be proctored in person for a minimum of five (5) procedures.

Renewal of Privilege: Demonstrated current competence and experience with at least five (5) MILD procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes. Annual training in radiation safety.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) – BASIC PERIOPERATIVE


Service Chief/Chair: Recommended Not Recommended Basic perioperative TEE examination is limited to non-diagnostic use within the customary practice of anesthesiology, focused on intraoperative monitoring. Except in emergent situations, diagnoses requiring intraoperative cardiac surgical intervention or postoperative medical/surgical management must be confirmed by an individual with advanced skills in TEE or by an independent diagnostic technique. Note that diagnostic TEEs performed on patients not having a surgical operation, e.g., to rule out thrombus before a cardioversion or ablation or to rule out a cardiac source of embolus, are not considered to be perioperative and cannot be used for certification. Perioperative TEE is defined as a TEE performed 1) intraoperative, 2) post-operative during the same hospitalization as surgery, or 3) preoperative in patients having surgery during the same hospitalization.

Criteria: National Board of Echocardiography certification in basic perioperative TEE OR completion of at least fifteen (15) TEE examinations which were personally performed and interpreted within one (1) consecutive year. Required Current Experience: Demonstrated current competence and experience with the performance of at least thirty (30) TEE examinations in the past 24 months. Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be proctored in person for a minimum of five (5) examinations by the Director of Perioperative Echocardiography (or designee). Renewal of privileges: Demonstrated current competence and experience with the performance of at least thirty (30) TEE examinations in the past 24 months.


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TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) – ADVANCED PERIOPERATIVE


Service Chief/Chair: Recommended Not Recommended The application of an advanced perioperative TEE examination is to utilize the full diagnostic potential of perioperative TEE including direction of the perioperative surgical decision-making process. Note that diagnostic TEEs performed on patients not having a surgical operation, e.g., to rule out thrombus before a cardioversion or ablation or to rule out a cardiac source of embolus, are not considered to be perioperative and cannot be used for certification. Perioperative TEE is defined as a TEE performed 1) intraoperative, 2) post-operative during the same hospitalization as surgery, or 3) preoperative in patients having surgery during the same hospitalization.

Criteria: Completion of a fellowship of at least 12 months’ duration dedicated to the perioperative care of surgical patients with cardiovascular disease OR a minimum of 24 months’ clinical experience dedicated to the perioperative care of surgical patients with cardiovascular disease that includes three-hundred (300) total reviewed TEE exams with one-hundred-fifty (150) independently performed examinations. Required Current Experience: Demonstrated current competence and experience with the performance of at least twenty-five (25) TEE examinations in the past 12 months. Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: New physicians will be proctored in person for a minimum of five (5) examinations. Renewal of privileges: Demonstrated current competence and experience with at least fifty (50) TEE examinations in the past 24 months AND National Board of Echocardiography (NBE) certification (and maintenance) in advanced perioperative TEE within five (5) years of completion of training.

VERTEBRAL AUGMENTATION PROCEDURES TO INCLUDE PERCUTANEOUS TECHNIQUES USED TO ACHIEVE INTERNAL VERTEBRAL BODY STABILIZATION


Service Chief/Chair: Recommended Not Recommended Criteria: Successful completion of an ACGME or AOA-accredited fellowship in pain medicine that included vertebral augmentation procedures or completion of an approved ACGME or AOA residency program that included 6 months of training in cross-sectional imaging (including CT and MR) and 4 month of training in image-guided interventional radiological techniques or at least one year of experience to include the performance of vertebral augmentations in at least five (5) patients as the primary operator, under the supervision of a qualified physician, and without complications. Applicants must also have completed training in radiation safety.


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Required Current Experience: Demonstrated current competence and experience with the performance of at least two (2) vertebral augmentation procedures in the past 12 months or completion of training in the past 12 months.

Focused Professional Practice Evaluation (FPPE NH/NP) guidelines: Newly privileged physicians will be monitored for at least two (2) procedure.

Renewal of Privilege: Demonstrated current competence and experience with at least four (4) vertebral augmentation procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes. Annual training in radiation safety

SPECIAL INSTITUTIONAL PRIVILEGES (SEPARATE APPLICATION REQUIRED)

A separate application is required to APPLY or REAPPLY for the following Special Privileges:

►FLUOROSCOPY

►HYPERBARIC OXYGEN THERAPY

►LASER

►ROBOTIC SURGICAL PLATFORM

►CHEMOTHERAPY (FOR NON-ONCOLOGIST)

►SEDATION PRIVILEGES (FOR A NON-ANESTHESIOLOGIST)

►BATTLEFIELD AURICULAR ACUPUNCTURE

PLEASE go to URL: www.med.umich.edu/i/oca/mss/pdocs for instructions, or contact your Clinical Department Representative.

http://www.med.umich.edu/i/oca/mss/pdocs.html


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CORE PROCEDURE LIST This list is not intended to be an all-encompassing procedure list. It defines the types of activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and inherent activities/procedures/privileges requiring similar skill sets and techniques.

To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not wish to request, initial, and date.

Anesthesiology 1. Perform history and physical exam 2. Assessment of, consultation for, and preparation of patients for anesthesia 3. Clinical management and teaching of cardiac and pulmonary resuscitation 4. Diagnosis and treatment of acute, chronic, and cancer-related pain 5. Evaluation of respiratory function and application of respiratory therapy 6. Image guided procedures e.g., peripheral nerve blocks, central line placement, arterial line placement 7. Management of critically ill patients 8. Monitoring and maintenance of normal physiology during the perioperative period 9. Relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic

procedures using sedation/analgesia, general anesthesia, regional anesthesia 10. Supervision and evaluation of performance of personnel, both medical and paramedical, involved in

perioperative care 11. Supervision of Certified Registered Nurse Anesthetists 12. Treatment of patients for pain management (excluding chronic pain management)

Pediatric Anesthesiology 1. Perform history and physical exam 2. Consultation for medical and surgical patients 3. Image guided procedures 4. Interpretation of laboratory results 5. Management of both normal perioperative fluid therapy and massive fluid and/or blood loss 6. Management of children requiring general anesthesia for elective and emergent surgery for a wide

variety of surgical conditions including neonatal surgical emergencies, , solid organ transplantation, and congenital disorders

7. Management of normal and abnormal airways 8. Management of nonsurgical cardiothoracic patients 9. Mechanical ventilation 10. Pharmacologic support of the circulation 11. Placement of venous and arterial catheters 12. Preoperative assessment of children scheduled for surgery 13. Recognition, prevention, and treatment of pain in medical and surgical patients 14. Sedation or anesthesia for children outside the operating rooms, including those undergoing

radiologic studies and treatment and acutely ill and severely injured children in the emergency department

15. Temperature regulation


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Pediatric Cardiac Anesthesiology 1. Perform history and physical exam 2. Anesthetic management for patients undergoing congenital cardiac surgery with or without

cardiopulmonary bypass, left heart bypass and /or deep hypothermic circulatory arrest 3. Anesthetic management of patients for cardiac pacemaker and automatic implantable cardiac

defibrillator placement, surgical treatment of cardiac arrhythmias, cardiac catheterization, and cardiac electrophysiologic diagnostic/therapeutic procedures

4. Image guided procedures 5. Management of patients with left ventricular assist devices 6. Transesophageal echocardiography - Probe placement

Non-invasive Pain Medicine 1. Perform history and physical exam 2. Behavioral modification and feedback techniques 3. Diagnosis and treatment of chronic and cancer related pain 4. Recognition and management of therapies, side effects, and complications of pharmacologic agents

used in management of pain 5. Rehabilitative and restorative therapy 6. Stress management and relaxation techniques 7. Superficial electrical stimulation techniques (e.g., TENS)

Interventional Pain Medicine

1. Chemical neuromuscular denervation (e.g., Botox injection) 2. Discography and intradiscal /percutaneous disc treatments 3. Epidural and intrathecal medication management 4. Epidural, subarachnoid, or peripheral neurolysis 5. Implantation of subcutaneous, epidural, and intrathecal catheters 6. Infusion port and pump implantation 7. Injection of joint and bursa, including but not limited to: sacroiliac, hip, knee, and shoulder joint

injections 8. Neuroablation with cryo, chemical, and radiofrequency modalities 9. Percutaneous and subcutaneous implantation of neurostimulator electrodes 10. Percutaneous needle tenotomy 11. Peripheral, cranial, costal, plexus, and ganglion nerve blocks 12. Prevention, recognition, and management of local anesthetic overdose, including airway

management and resuscitation 13. Spinal injections including epidural injections: interlaminar, transforaminal, nerve root sheath

injections, and zygapophysial joint injections 14. Trigger point injection


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ACKNOWLEDGEMENT OF PRACTITIONER I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at Michigan Medicine, and I understand that: a. In exercising any 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 insuch situation my actions are governed by the applicable section of the Medical Staff Bylaws orrelated documents.

Signed Date

SERVICE CHIEF / DEPARTMENT CHAIR'S RECOMMENDATION I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s): Recommend all requested privileges. Recommend privileges with the following conditions/modifications: Do not recommend the following requested privileges:

Privilege Condition/Modification/Explanation 1. 2. 3. 4.

Notes

Service Chief Signature Date

Department Chair Signature Date

FOR MEDICAL STAFF SERVICES DEPARTMENT USE ONLY

Credentials Committee Action Date Executive Committee on Clinical Affairs Action Date Governing Board Action Date

department of anesthesiology - university of michigan health system

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