PEDIATRIC EMERGENCY MEDICINE. Delineation of Privileges. Applicant's
Name (please print): Must be an MD/DO and have completed Threshold Criteria
...
PAGE 1 OF 3
Fairview Health Services
PEDIATRIC EMERGENCY MEDICINE 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\Pediatric Emergency Medicine.doc Approved: 11/03; 6/09 (new format); 8/11; 9/11; 10/11;6/12;6/22/12;9/12
PAGE 2 OF 3
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
Fairview Ambulatory Entity Code FV Clinics = Fairview Free-standing Ambulatory Clinics MGASC = Fairview Maple Grove Ambulatory Surgery 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
PEDIATRIC EMERGENCY MEDICINE Must meet one (1) of the following Paths: Threshold Criteria
Path I: ●Pediatrics or Emergency Medicine residency program ●Pediatric Emergency Medicine subspecialty board certification (or admissible to take the board) by American Board of Pediatrics or American Board of Emergency Medicine Path II: ●Emergency Medicine or any combined Emergency Medicine (e.g. EM/internal medicine, EM/pediatrics) residency program ●Board certification (or admissible to take the board) by American Board of Emergency Medicine Path III: ●Pediatrics or Family Medicine residency program ●Pediatrics board certification (or admissible to take the board) by American Board of Pediatrics or Family Medicine board certification (or admissible to take the board) by the American Board of Family Medicine. ●Technical capabilities and practice experience which meet standards set by site medical directors and approved by the site Board of Directors ●Current PALS and ATLS certification required to function independently. Technical capabilities and practice experience In the past 24 months has provided care to 100 acutely ill or injured children in an emergency, urgent care or hospital setting.
Core Privileges
Check Entity(ies) Where Privileges Requested Competency Cross out privileges you do not Measures/ perform Hospital Entities Ambulatory Required # Privileges include being able to assess, Cases in Past work-up, and provide initial treatment 24 Months UMMC FSH FRH FNH FLH FV Clinics and stabilization to children (infants through young adult) who present in the Emergency Department with any illness N/A N/A N/A N/A 100 or injury, condition or symptom, as well as providing those services necessary to ameliorate minor illnesses or injuries, and to assess these patients in order to determine if more definitive services are necessary. Privileges also include, but are not limited to: ● Local anesthesia , moderate ● Foreign body removal and deep sedation (if trained ● Fracture/dislocation immobilization in Emergency Medicine or ● Initial ordering of imaging studies and evaluation of the results to the degree of Pediatric Emergency formulating a plan of action Medicine) ● Management of care of patients who are admitted to hospital for observation or ● Cardiac arrest management for less than 24 hours which includes determining and placing the initial order for ● Thoracentesis patient placement ● Endotracheal airways ● Lumbar puncture Consultation is required for all patients admitted to the applicable entity, unless you currently hold admitting privileges at that entity.
PAGE 3 OF 3
Special Request Privileges NOTE: You may also obtain referenced additional privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms
Moderate and Deep Sedation (not required if trained in Pediatrics Emergency Medicine or Emergency Medicine) - You may also obtain referenced additional
Competency Measures/ Required # Cases in Past 24 Months
UMMC
FSH
AF
AF
N/A
Check Entity(ies) Where Privileges Requested Hospital Entities FRH
Ambulatory
FNH
FLH
FV Clinics
N/A
N/A
N/A
N/A
N/A
N/A
privilege form (AF) at www.fairview.org/credentialing/PrivilegeForms
Point of Care Ultrasound Initial Appointment or First Request - Must meet one (1) of the following: 1) Successful completion within the past 24 months of an ACGME or AOA approved residency training program that included training specific to point of care ultrasound. Documentation must include a letter from the Residency Director, Director of Emergency Ultrasound or Department Chair documenting training and use of point of care ultrasound.
Initial Appointment/ First Request = See specific requirements Reappointment = 50 cases
OR 2) Documentation of successful completion of a training course specific to point of care ultrasound within the past 24 months. Training course must be a minimum of 8 hours and include the physics of ultrasound and hands on training.
N/A
N/A
OR 3) If training (#1 or 2 above) was completed longer than 24 months ago, must document successful completion of a minimum of 50 total point of care ultrasound exams in the past 24 months (by requesting this privilege, I attest to completing appropriate training course in point of care ultrasound).
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
VERIFICATION OF PATIENT MANAGEMENT & PARTICIPATION FOR PEDIATRIC EMERGENCY MEDICINE 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. ____ Pediatric Emergency Medicine - 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
