Psychiatry Clinical Privileges

Name: ______Effective from ______/______/______to ______/______/______

❏ Initial privileges (initial appointment) ❏ Renewal of privileges (reappointment)

All new applicants must meet the following requirements as approved by the governing body, effective: ____/____/____. (Date accepted by PQASC)

Applicant: Check the “Requested” box for each privilege requested. Applicants are responsible for producing required documentation for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. Please provide this supporting information separately.

[Department/Program Head or Leaders/ Chief]: Check the appropriate box for recommendation on the last page of this form and include your recommendation for any required evaluation. If recommended with conditions or not recommended, provide the condition or explanation on the last page of this form.

With respect to the "standards for currency", the currency for exams or procedures suggested as a threshold are developed by practitioners in the field and are believed to be fair and reasonable and are not intended as a barrier to practice or service delivery. The focus of the standard is on those who are close to or below the threshold, so the situation can be discussed with the department head, and is not on the precise number for those who are well above the threshold. Regardless of the currency number, acceptable results must be demonstrated, especially for procedures with significant risk. Please review the four principles document for more information.

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

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

Note: The dictionary will be reviewed over time to ensure it is reflective of current practices, procedures and technologies.

Description

Psychiatry Working Copy Nov 21,2013 Psychiatry Clinical Privileges

Psychiatry is the branch of medicine concerned with disorders in relation to people with cognitive (mental, emotional and behavioral) disorders alone or as they coexist with other medical or surgical disorders across the life span. Psychiatrists practice biopsychosocial assessment, diagnosis, treatment, rehabilitation and prevention of disorders.

Royal College definition (with slight modification):

Psychiatry is the branch of medicine concerned with the biopsychosocial practice of assessment, diagnosis, treatment, rehabilitation and prevention of cognitive (mental, emotional and behavioral)disorders alone or as they coexist with other medical or surgical disorders across the life span.

Qualifications for psychiatry Initial privileges: To be eligible to apply for privileges in general psychiatry, the applicant must meet the following criteria:

Current certification in Psychiatry by the Royal College of Physicians and Surgeons of Canada

AND/OR Recognition of certification as an Psychiatrist by the College of Physicians and Surgeons of Britis h Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both th e College and the governing body of the [Health Authority]

Required current experience: Provision of inpatient, outpatient, or consultative services for at least 30 patients, 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.

Renewal of privileges: To be eligible to renew privileges in general psychiatry, the applicant must meet the following criteria: Current demonstrated competence and an adequate volume of experience ([n] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical

Psychiatry Working Copy Nov 21,2013 Psychiatry Clinical Privileges and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Psychiatry ❑ Requested Admit, evaluate, diagnose, treat, and provide consultation to patients presenting with mental, behavioral, addictive, or emotional disorders (e.g., psychoses, depression, anxiety disorders, substance abuse disorders, developmental disabilities, sexual dysfunctions, and adjustment disorders). Privileges include providing: consultation to clinicians and/or third parties (e.g. attorneys, schools, insurers) regarding mental disorders; pharmacotherapy; psychotherapy; psychoeducation; and the ordering of diagnostic and/or laboratory tests. This may include a relevant physical exam. Assess, stabilize, and determine the 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 procedures list and such other procedures that are extensions of the same techniques and skills.

Core procedures list This is not intended to be an all-encompassing procedures list. It defines the types of activities/procedures/privileges that recently graduated residents in this specialty perform at this organization would competently perform and inherent activities/procedures/privileges requiring similar skill sets and techniques.

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

. Assessment o Diagnostic interview o Cognitive screen o Risk Assessment (Suicide, Violence, Safety) o Capacity

. Intervention o Supportive therapy/Crisis intervention o Cognitive behaviour therapy o Interpersonal therapy o Group therapy o Family therapy o Dialectical behavioral therapy

o Mindfulness o Psychodynamic psychotherapy o Motivational interviewing o Other (please add)

Qualifications for child and adolescent psychiatry

Initial privileges: To be eligible to apply for privileges in child and adolescent psychiatry, the applicant must meet the following criteria:

Current certification in Psychiatry by the Royal College of Physicians and Surgeons of Canada

AND/OR Recognition of certification as an Psychiatrist by the College of Physicians and Surgeons of Britis h Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both th e College and the governing body of the [Health Authority]

AND/OR

Practicing as an Psychiatrist in British Columbia at the time these standards were introduced MM YYYY

Renewal of privileges: To be eligible to renew privileges in general psychiatry, the applicant must meet the following criteria: Current demonstrated competence and an adequate volume of experience ([n] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Child and adolescent psychiatry ❑ Requested Admit, evaluate, diagnose, treat, and provide consultation to children and adolescents who suffer from developmental, mental, behavioral, addictive, or emotional disorders. Privileges include providing consultation with physicians in other fields regarding mental, behavioral, or emotional disorders, pharmacotherapy, psychotherapy (individual family or group), behavior modification, cognitive therapy, treatment of psychiatric disorders in children and adolescents with sever physical illness, consultation to the courts, and emergency psychiatry, as well as the ordering of diagnostic laboratory tests and prescribing medications. Includes performance of history and physical exam. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Qualifications for addiction psychiatry

Initial privileges: To be eligible to apply for privileges in addiction psychiatry, the applicant must meet the following criteria: The same as for general psychiatry, plus successful completion of an accredited ACGME or AOA residency in addiction psychiatry.

AND/OR

Current subspecialty certification or active participation in the examination process (with achievement of certification within [n] years) leading to subspecialty certification in addiction psychiatry by the American Board of Psychiatry and Neurology or completion of a certificate of added qualifications in addiction psychiatry by the American Osteopathic Board of Neurology and Psychiatry.

Required current experience: Provision of inpatient, outpatient, or consultative services, reflective of the scope of privileges requested, for at least 15 patients during the past 12 months or successful completion of an ACGME- or AOA accredited residency or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in addiction psychiatry, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of experience ([n] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Addiction psychiatry ❑ Requested Admit, evaluate, diagnose, treat, and provide consultation to adult patients with alcohol, drug, or other substance-related disorders and to individuals with the dual diagnosis of substance-related and other psychiatric disorders. Treatment modalities include detoxification, management of overdoses, and maintenance pharmacotherapy. Includes performance of history and physical exam. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Qualifications for forensic psychiatry

Initial privileges: To be eligible to apply for privileges in forensic psychiatry, the applicant must meet the following criteria: The same as for general psychiatry, plus successful completion of an ACGME- or AOA- accredited residency in forensic psychiatry.

AND/OR

Current subspecialty certification or active participation in the examination process (with achievement of certification within [n] years) leading to subspecialty certification in forensic psychiatry by the American Board of Psychiatry and Neurology.

Required current experience: Provision of inpatient, outpatient, or consultative services for at least [n] patients, 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.

Renewal of privileges: To be eligible to renew privileges in forensic psychiatry, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of experience (inpatient, outpatient, or consultative services for at least [n] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Forensic psychiatry ❑ Requested Evaluate, diagnose, treat, and provide consultation to patients or individuals involved with the legal system (civil, criminal, and administrative law) and provide specialized treatment to those incarcerated in jails, prisons, and forensic psychiatry hospitals. Includes performance of history and physical exam. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Qualifications for geriatric psychiatry

Initial privileges: To be eligible to apply for privileges in geriatric psychiatry, the applicant must meet the following criteria: The same as for general psychiatry, plus successful completion of an ACGME- or AOA- accredited residency in geriatric psychiatry.

AND/OR

Current subspecialty certification or active participation in the examination process (with achievement of certification within [n] years) leading to subspecialty certification in geriatric psychiatry by the American Board of Psychiatry and Neurology.

Renewal of privileges: To be eligible to renew privileges in geriatric psychiatry, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of experience (inpatient, outpatient, or consultative services for at least [n] patients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Geriatric psychiatry ❑ Requested Admit, evaluate, diagnose, treat, and provide consultation to elderly patients with mental and emotional disorders, including those areas that are unique to the care of the elderly (e.g. multiple comorbid medical disorders and degenerative disorders). Privileges include providing consultation with physicians in other fields regarding mental, behavioral, or emotional disorders, pharmacotherapy, psychotherapy, family therapy, behavior modification, consultation to the courts, and emergency psychiatry, as well as the ordering of diagnostic laboratory tests, and prescribing medications. Includes performance of history and physical exam. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Non-core Privileges (See Specific Criteria) Non-core privileges are permits for activities that require further training, experience and demonstrated competence. Non-core privileges are requested individually in addition to requesting the core. Each individual requesting non-core privileges should meet the specific threshold criteria as outlined.

Non-core privileges: Hypnotherapy ❑ Requested Initial privileges: Successful completion of an ACGME- or AOA-accredited residency in psychiatry and evidence of at least 40 hours of postdegree training that included at least 20 hours of individualized training by a practitioner experienced in the procedure.

Required current experience: Demonstrated current competence and evidence of the performance of at least [n] hypnotherapy procedures in the past 12 months or completion of training in the past 12 months.

Renewal of privileges: Demonstrated current competence and evidence of the performance of at least [n] hypnotherapy procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Source: HCPro’s Clinical Privilege White Paper: Hypnosis—Procedure 69.

Non-core privileges: Electroconvulsive therapy (ECT) ❑ Requested Initial privileges: Successful completion of an ACGME- or AOA-accredited residency program in psychiatry.

Required current experience: Demonstrated current competence and evidence of the provision of at least 10 ECT treatments to at least three patients during the past 12 months or completion of training in the past 12 months. Treatment must have included the evaluation of the patient for treatment need and suitability and immediate post-treatment follow-up and evaluation at the completion of the treatment course.

Renewal of privileges: Demonstrated current competence and evidence of the provision of at least [n] ECT treatments to at least [n] patients during the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Source: HCPro’s Clinical Privilege White Paper: Electroconvulsive Therapy—Procedure 1.

Context Specific Privileges Context refers to the capacity of a facility to support an activity

Context specific privileges: Administration of procedural sedation ❑ Requested See “Hospital Policy for Sedation and Analgesia by Non-anesthesiologists.”

Acknowledgment 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 [facility name], 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 in such situation my actions are governed by the applicable section of the medical staff bylaws or related documents.

Signed: ______Date: ______

[Department/Program Head or Leaders/Chief]’s Recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above- named applicant and: ❑ Recommend all requested privileges ❑ Recommend privileges with the following conditions/modifications: ❑ Do not recommend the following requested privileges: Privilege Condition/modification/explanation Notes: ______

[Department/Program Head or Leaders/ Chief ] Signature:

______Date:

______

FOR MEDICAL AFFAIRS USE ONLY (Tailor to Health Authority Process)

Credentials committee action Date: ______

Medical executive committee action Date: ______Board action Date: ______

Psychiatry Working Copy Nov 21,2013