- 1 - KALEIDA HEALTH

Name: ______Date: ______

DELINEATION OF PRIVILEGES - GENERAL SURGERY

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive.

GENERAL STATEMENTS - Privileges in Adult Surgery are separated into the following divisions: General Surgery and Plastic Surgery. Applicants desiring procedure privileges in more than one division must complete separate forms for each.

Procedures designated with an asterisk (*) indicate that Moderate or Deep Sedation may be required. If you do not have Moderate or Deep Sedation privileges, you must invite a Kaleida Health anesthesiologist to participate in the procedure.

Procedures are also separated into levels of complexity (Level I-A, Level I-B, Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I-A or Level I and are granted upon evidence of successful completion of residency training. Level II procedures may or may not require evidence of additional training beyond residency. Documentation of additional training and/or experience is required for all Level III procedures.

LEVEL I-A PRIVILEGES Procedures which involve primarily wound care, can be done under local anesthetic and occasionally involve application of temporary skin coverage or application of agents to expedite wound healing. Can be performed by any competent surgeon. Applies to patients who are greater than or equal to 12 years old. Debridement, Non-Selective Debridement, Selective Infection, Incision & Drainage Negative Pressure Therapy Burn Excision & Debridement, Minor Debridement of Skin, Partial Debridement of Skin, Full Debridement of Skin, Subcutaneous Decubitus Ulcer Acellular Dermal Replacement Dermal Skin Substitute Allograft, Acellular Dermal

LEVEL I-A PRIVILEGES With Following (includes all of the above) PHYSICIAN Not Requirements** REQUEST Granted Granted* (Provide Details)

LEVEL I-B PRIVILEGES With Following PHYSICIAN Not Requirements** REQUEST Granted Granted* (Provide Details)

Vascular Lab – Read and interpret carotid, venous and arterial imaging studies.

General Surgery 6/2019

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LEVEL I (CORE) PRIVILEGES

Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually.

LEVEL I (CORE) PRIVILEGES Procedures which involve primarily wound care, can be done under local anesthetic and occasionally involve application of temporary skin coverage or application of agents to expedite wound healing. Can be performed by any competent surgeon. Applies to patients who are greater than or equal to 12 years old. Admission and Follow-Up Thorascopic empyema drainage History and Physical for diagnosis and treatment plan Gallbladder (open & laparoscopic cholecystectomy, incision, open excision, bypass) Thyroid/Parathyroid (aspiration, biopsy, resection) Common Duct (exploration, repair, bypass) Adrenal (resection, biopsy, repair) Other Biliary (miscellaneous procedures) Tongue (biopsy, suture) Pancreas (incision, biopsy, cyst drainage, distal resection) Salivary Gland (biopsy, repair) Anoscopy Mouth and Face (drainage, biopsy, resection, repair) Colonoscopy *Trachea (open tracheostomy, endoscopy, bronchoscopy) Sigmoidoscopy (rigid, flexible) *Veins (varicose ligations & stripping) EGD *Puncture of Vessel (cutdowns, catheterization) Hernia (inguinal, femoral, umbilical, open or laparoscopic, other) *Renal dialysis shunt Other abdomen (miscellaneous procedures) *Lymphatic System (biopsies) Kidney (repair, resection) Bone Marrow & Spleen (biopsies, resections, repairs) Genitalia (excision hydrocele, repair, biopsy) Esophagus (incision, ostomy, distal resection) Testes (biopsy, resection, repair) *Gastric (incision, excision, biopsy) Cord & Epididymis (repair, resection, ligation) Highly Selective Vagotomy Penis (biopsy, circumcision [adult]) *Bowel (repair, biopsy, endoscopy, resection, anastomosis, Tubes & Ovaries (marsupialization, biopsy, resection) colostomy) Other Gastric (vagectomy, bypass, repair) Uterus (total abdominal hysterectomy) Other Intestinal (ostomies, revision, repair) Extremities (amputations, disarticulations) Appendix (open & laparoscopic appendectomy) Breast (mastectomy, biopsy, excision, repair) Rectal & Perirectal Skin and Subcutaneous (endoscopy, biopsy, excision, repair) (incision, excision, biopsy, grafts) Anal (incision, excision, biopsy, repair) Internal Injury of Chest, Abdomen, and Pelvis Liver Subcutaneous Venous Access Port (ie Mediport) (biopsy, wedge or segmental resection, repair)

ACS Level I Trauma (request only if working at OCH) With Following PHYSICIAN Granted Not Requirements** Requirement: Successful completion of the ATLS at least once REQUEST Granted* (Provide Details) and for providers that have not been actively practicing in a trauma setting within the past two (2) years, recertification will be required. [email protected]. ACS Level 1 Trauma - Internal Injury of Chest, Abdomen, and Pelvis – Trauma Evaluation and Laparotomy for any age.

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Requests for pediatric surgical privileges, <18 yrs, unless otherwise specifically noted on this form for level II or level III, must be submitted in writing listing the specific privileges being requested along with documentation of training and case listings from the last 2 years for each privilege requested. This will then be reviewed by the Chief of Pediatric Surgery. LEVEL II PRIVILEGES With Following Procedures listed below, including those not listed in Level I, PHYSICIAN Not Requirements** may require documentation of additional experience or REQUEST Granted Granted* (Provide Details) training. Applies to patients who are greater than or equal to 18 years old (unless otherwise noted). Laparoscopic minimally invasive pectus excavatum repair. Thymectomy Salivary gland resection Radical Neck Dissection Radical Iliac Node Dissection Radical Groin Dissection Total Esophagectomy, Bypasses Total Gastrectomy Esophagogastroplasty ERCP Related Procedures Excision Ampulla of Vater Pancreatic Duct Sphincterotomy Pancreatic Duct Sphincteroplasty Radical Sub-total Pancreatectomy Hip Disarticulation Colectomy with ileal pouch Extracorporeal Membrane Oxygenation (ECMO) Endoscopy and Endoscopic Procedures Colonoscopy with Polypectomy Percutaneous liver biopsy Esophageal manometry PH monitoring Endoscopic Control of Hemorrhage: - Variceal - Non-variceal Enteroscopy Small bowel suction/capsule Bx Small bowel enteroscopy Endoscopic ultrasound PEG Balloon tamponade (Sengstaken) for bleeding esophageal/gastric varices Vascular Applicant must document evidence of attending course and be proctored for two cases by someone who has done more than ten. Radiofrequency Ablation (VNUS) -with Perforator Technique -List other techniques:

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INTERSTIM THERAPY Requires documentation of having received training during ACGME accredited Surgery residency OR (1) attending a Theory & Technique course on InterStim Therapy, observing 2 cases performed by an InterStim-credentialed physician; OR (2) completing the InterStim on-line educational program and successfully completing training with the InterStim simulator; OR (3) completing the InterStim on-line education program and observing chronic lead placement at an InterStim experience physician site. If either pathway (1) or pathway (2) or pathway (3) is selected, then the physician requesting privileges in InterStim Therapy must be proctored on his first case by an InterStim credentialed physician and the requesting physician’s performance deemed satisfactory by the proctoring physician. Interstim Therapy

LEVEL III PRIVILEGES PHYSICIAN Granted Not With Following Applies to patients who are greater than or equal to 18 years REQUEST Granted* Requirements** old. (Provide Details) Procedures which categorically require documentation of additional training or significant experience, such as high risk procedures or new procedures. Hepatic Duct Enteric Anastomosis Trans-sacral Rectosigmoidectomy Anal Sphincter Repair Rectal Pouches ADVANCED MULTIPORT LAPAROSCOPIC PROCEDURES Applicant must document evidence of training in residency, or provide an attendance certificate from an approved training course. The applicant must document having served as first assistant five cases OR completion of 1 year Fellowship trained in laparoscopic surgery. Subsequent volume criteria at each reappointment is [required]. Laparoscopic gastric procedures to include: gastric fundoplication, gastric resection, gastroenterostomy, vagotomy, duodenal procedures and gastric tube placement (excluding bariatric surgery) [5] Laparoscopic solid organ procedures to include: adrenal, pancreas, kidney and liver splenectomy and spleen [5] Laparascopic intestinal procedures to include: small and large bowel resection and anastomosis, right and left colon resection, low anterior resection, abdominal perineal resection, colostomy formation, colostomy closure (excluding bariatric surgery) [5] ADVANCED SILS (SINGLE PORT) COLECTOMY Applicant must have multiport laparoscopic colectomy privileges and has performed at least 40 multiport laparoscopic colectomies within Kaleida Health. Colectomy [40] BARIATRIC SURGICAL PROCEDURES Applicants must document evidence of training in residency or fellowship or provide an attendance certificate from an approved training course. In general, the applicant must document having served as first assistant for a specific number of cases (required number in parentheses), then as primary surgeon [required]. * For Lap Band type credentialing, applicant must present a certificate of having completed the appropriate course required by the company. ** For Gastric Sleeve credentialing, applicant must have active privileges in gastric bypass and must present a certificate of having completed the appropriate course in sleeve gastrectomy. Open Gastric Bypass (5) [25] Open Gastric Lap Band * (5) [10] Laparoscopic Gastric Bypass (5) [25] Laparoscopic Gastric Lap Band * (5) [10]

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LEVEL III PRIVILEGES PHYSICIAN Not With Following (CON’T) REQUEST Granted Granted* Requirements** Applies to patients who are greater than or equal to 18 years (Provide Details) old. Laparoscopic Gastric Sleeve ** (5) [10] Other (Scopinaro, vertical banded, etc) HAND-ASSISTED LAPAROSCOPIC NEPHRECTOMY (HALN), ADRENALECTOMY, NEPHROADRENALECTOMY Requires completion of hand-assisted laparoscopic nephrectomy course including “hands on” experience (attach documentation) and performance at least 3 hand-assisted laparoscopic nephrectomies performed with the assistance of a Kaleida credentialed laparoscopic surgeon in attendance; OR hand-assisted laparoscopic nephrectomy training in an ACGME accredited training program (verification letter from program director) Hand-Assisted Laparoscopic Nephrectomy, Adrenalectomy, Nephroadrenalectomy PERCUTANEOUS TRACHEOSTOMY Requires satisfactory performance of 5 procedures proctored by a surgeon currently credentialed to perform this procedure. Percutaneous Tracheostomy ACCESS TO SPINE Requires satisfactory performance of 5 procedures proctored by a surgeon currently credentialed to perform this procedure. Access to Spine GREENFIELD FILTERS Applicant must provide evidence of adequate training for initial approval. Greenfield Filters HIGH RISK PROCEDURES Applicant must provide evidence of adequate training for initial approval. Hepatic Lobectomy Revision Bile Duct Anastomosis Pancreatoduodenectomy ORGAN TRANSPLANTATION PROCEDURES Requires transplant fellowship Kidney Pancreas CRYOSURGICAL PROCEDURES OR RADIOFREQUENCY ABLATION Requires completion of an approved training course & a minimum of 5 cases / procedure for initial approval. List Procedures:

LASER PROCEDURES Requires completion of an approved training course and documentation of ten (10) cases per procedure requested for initial approval. List Procedures:

COLON-RECTAL SURGERY (Ages => 12 yrs - < 18 yrs) Procedures requiring documentation of training & experience in colon-rectal surgery and Certification by the American Board of Colon- Rectal Surgery Trans-sacral Rectosigmoidectomy Anal Sphincter Repair Rectal Pouches Endoscopy and Endoscopic Procedures

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MODERATE/CONSCIOUS SEDATION PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course – cost $199.00 (www.asahq.org/education/online- learning/safe-sedation-training-moderate) or Medsimulation course – cost $75.00 (www.medsimulation.com) receiving a score of 85% or above. * Note: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via e-mail ([email protected]) or fax (859-5592 or 859-5593). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call 716-859-5515 for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: https://promedcert.com/ $179.00, www.buffalocpr.com/aclsatubcampus.html $135.00 or www.wnyhe.com/courses/acls/ $175.00.) 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

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MULTIPORT ROBOTIC PROCEDURES – GENERAL SURGERY LEVEL I 1. Applicant must have unrestricted privileges for open and/or laparoscopic surgery procedures for which robot assisted surgeries/procedures will be performed. 2. When 2 robotic cases are completed at a particular level (as per the DOP level I, II, III) the applicant is then qualified to perform any cases in that level. 3. Current medical staff members: Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 4. Initial applicants to medical staff: A. If completing residency or fellowship - Documentation from the program director of the accredited training program in which robotics is a part of the experience obtained and verification of the individual’s competency in the use of the robot for the procedures requested. This would include a case log and documentation as to the number of cases the applicant has been involved in. AND 2 cases proctored by a robotics experienced surgeon in the same specialty as the applicant (if the applicant is trained in a Kaleida Health residency program it is up to the discretion of the program director if trainee is required to have any proctored cases). B. If > 1 year since completion of residency or fellowship and held robotics privileges at another institution - Documentation from the Chair of that surgical specialty department of the previous institution stating a history of safe use of the requested robotics surgeries. AND 10 cases minimum, at least 2 of which were during the previous year, as the primary surgeon; documentation from hospital or physician case log. C. If no robotics privileges held at another institution - Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. 5. Re-privileging - To demonstrate current competence and maintain privileges, 12 cases must be performed at Kaleida Health during the 2-year reappointment cycle. 6. There will be periodic evaluations to monitor outcomes of all surgeons including patient safety, intra-op complications and O.R. time efficiency. 7. In the future if a Robot is placed at Children’s Hospital these adult criteria may need to be revisited. 8. It is the responsibility of the surgeon applying for robotic privileges to arrange for the proctor. All efforts should be made by the applicant to secure a Kaleida Health surgeon to proctor. If this is not feasible then an outside proctor can be used. If the proctor does not have privileges at Kaleida Health and is going to assist in any way other than observation and discussion, the proctor must obtain temporary Kaleida Health privileges. Proctor - To qualify to Proctor Level I Robotic Assisted Surgery robotic surgery, in the Kaleida system an applicant must also have completed a minimum of (25) Level I Robotic Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) a. Abdominal explorations including intestinal resections for benign and malignant disease- lysis of adhesions- solid organ biopsy-lymph node biopsy b. Appendectomies c. Cholecystectomy d. Colon excluding total colectomies e. Gastrectomy – Wedge and Sleeve f. Gastric bypass (Gastric bypass or gastric sleeve resection) g. Hernias – inguinal or ventral including incisional h. Diaphragmatic hernias both congenital and acquired-thereby including all forms of fundoplications and primary diaphragmatic repair May Act as a Proctor for Level I Robotic Assisted Surgery in the Department of Surgery.

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SINGLE PORT/REDUCED PORT ROBOTIC PROCEDURES – GENERAL SURGERY LEVEL I If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be “approved with proctoring” PRIOR to performing the procedure within Kaleida.

1. Applicant must have unrestricted privileges to perform multiport robot assisted surgery.

2. Applicant must have completed 25 multiport robot assisted surgeries.

3. Applicant must provide documentation of one day dedicated hands-on experience training course designed for single port robotic surgery

4. Applicant must have first three (3) single port robotic surgery cases proctored.

5. Applicant must perform twenty five (25) robot-assisted surgeries each year with satisfactory results to maintain privilege. This may include a combination of both single and multiport robot assisted surgeries.

6. Interruption of robot assisted surgery for more than 3 months will result in loss of full privileges; however, the surgeon will maintain provisional privileges with ability to reapply for unrestricted full privileges. Further, the surgeon must complete and provide documentation of completion of at least 4 hours of use of the Surgical Simulator prior to performing any robot assisted surgeries.

*To qualify to proctor robotic surgery, an applicant must also have completed a minimum of twenty-five (25) single port robotic surgery cases with satisfactory outcomes, and must agree to be present in the OR during the entire surgical procedure being proctored. PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) Single Port/Reduced Port Robot Assisted Cholecystectomy May Act as a Proctor for Single Port/Reduced Port Robotic Assisted Surgery in the Department of Surgery.

MULTIPORT ROBOTIC PROCEDURES – GENERAL SURGERY LEVEL II 1. Applicant must have Robotic Level I privileges at Kaleida Health. 2. Applicant must have 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 3. Proctor - To qualify to Proctor Level II Robotic Assisted Surgery in the Kaleida system, an applicant must also have completed a minimum of (25) Level II Robotic Assisted Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) a. Adrenalectomy b. Benign and malignant soft tissue malignancy c. Gastrectomy - Total d. Liver wedge resections and thermal energy procedures e. Pancreas excluding those involving the head but including distal pancreatectomy with and without splenectomy-enucleation-drainage procedures- necrosectomies f. Splenectomy g. Total colectomy May Act as a Proctor for Level II Robotic Assisted Surgery in the Department of Surgery.

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MULTIPORT ROBOTIC PROCEDURES – GENERAL SURGERY LEVEL III 1. Applicant must have Robotic Level II privileges at Kaleida Health. 2. Applicant must have 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 3. Proctor - To qualify to Proctor Level III Robotic Assisted Surgery in the Kaleida system, an applicant must also have completed a minimum of (25) Level III Robotic Assisted Surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. PHYSICIAN Not With Following REQUEST Granted Granted* Requirements** (Provide Details) a. Biliary resections b. Ileoanal pullthrough with pouches c. Liver resections including placement of intra-arterial infusion pumps d. Pancreatic head procedures including Whipple, Frey and Beger May Act as a Proctor for Level III Robotic Assisted Surgery in the Department of Surgery.

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KEY *NOT GRANTED DUE TO: **WITH FOLLOWING REQUIREMENTS Provide Details Below Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define)

DETAILS:______

______

National Practitioner Databank Disclaimer Statement: - Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.)

______/______Signature of Applicant Date

_____ I recommend approval of the procedures requested by the applicant:____ a) as requested ____ b) as amended

_____ I have consulted with Pediatric Surgery on ___/___/____who agrees to recommend approval of the requested Pediatric Level II/III privileges in General Surgery.

______/______Signature of Chief of Service Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED FORM FOR YOUR RECORDS.

General Surgery DOP 6/2019