PERFUSIONIST Professional Practitioner Scope of Practice
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PAGE 1 OF 2 Fairview Health Services PERFUSIONIST Professional Practitioner Scope of Practice Applicant’s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I need to the following Fairview Entity Box on Privilege I Want to Work at the Following Fairview Entity Form Inpatient/hospital(s) Individual Fairview hospital(s) Fairview Maple Grove Medical Center University of Minnesota Medical Center, Fairview (UMMC) (Ambulatory Care Center) 1, 2 Fairview Maple Grove Ambulatory Surgery Center 1 Fairview Maple Grove Ambulatory Surgery Center (MGASC) Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Individual Fairview hospital where clinic is affiliated Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Ambulatory Clinics 1 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. THRESHOLD CRITERIA Certification: Certification by American Board of Cardiovascular Perfusion (ABCP) OR Documentation of being in the process of ABCP examination; must document successful completion of certification process within one year Education: Graduation from a perfusion program accredited by the Council on Allied Health Education or Canadian Medical Association OR Must document training equivalent to above Experience: Completion of training within past 24 months OR Documentation of having performed at least 40 perfusions annually for the past 24 months Sponsorship: The applicant must submit a Fairview Allied Health Professional Sponsorship Form completed by a physician in good standing on staff at the Fairview entity to which the applicant is applying. The Sponsorship Form is attached to this privilege form. z:\common\forms\cvo\Privilege Forms\Perfusionist.doc 11/14/95 Revised: 5/96; 10/01; 8/06 (subcomm); 6/09 (new format);9/12 PAGE 2 OF 2 Fairview Hospital Entity Codes Fairview Ambulatory Entity Code UMMC - University of Minnesota Medical Center, Fairview FV Clinics = Fairview Free-standing Ambulatory Clinics FSH - Fairview Southdale Hospital MGASC = Fairview Maple Grove Ambulatory Surgery Center FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical 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 PERFUSIONIST Threshold Must meet Threshold Criteria listed on page 1 Criteria Check Entity(ies) Where Privileges Requested Scope of Assist with cardiopulmonary bypass, Practice autotransfusion and various methods of Hospital Entities Ambulatory long term cardiopulmonary support. UMMC FSH FRH FNH FLH FV Clinics Duties/Responsibilities : • Place patients on heart lung machine during bypass surgery N/A N/A N/A N/A Responsible for circulation of body fluid during procedure Perfusionist may, based on perceived abnormalities, make appropriate reports, implement emergency procedures, or (upon a physician's order) make changes in the treatment regimen, in accordance with perfusion protocols developed by the hospital and its medical staff. I attest that my professional liability insurance covers the responsibilities listed. Signature Date Sponsoring Physician Signature Date PROFESSIONAL STAFF SPONSORSHIP FORM Professional Staff Practitioner’s Name_________________________________________________________ Sponsoring Physician’s Name:________________________________________________________________ (Sponsoring physician must be a member in good standing of the Medical Staff at the entity(ies) to which the applicant is applying) SPONSORING PHYSICIAN STATEMENT: I support the application of the above named individual for the services requested and agree to all of the terms, conditions and obligations associated with my supervising/sponsoring said individual as specified in the policies and rules of the Fairview entity(ies) to which applicant is applying. _________________________________________________________ _______________________ Sponsoring Physician Signature Date _____________________________________________________________________________________ Sponsoring Physician Name – PLEASE PRINT GROUP PRACTICE SUPERVISION In the event the above named individual for the services requested above will be supervised by several practitioners in a group practice, the group practice _________________________________ (name of group) shall support the application of the above named individual for the services requested and agree to all the terms, conditions and obligations associated with the supervision of said individual as specified in the policies and rules of the Fairview entity(ies) to which the applicant is applying relevant to the individual’s practice at the hospital. The group practice promises that any practitioners providing the supervision shall be a member in good standing of the medical staff of the Fairview entity(ies) to which applicant is applying. ___________________________________________________ _________________________ Officer of Group Date c:\common\forms\cvo\Credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06; 10/10 PROFESSIONAL STAFF PERFORMANCE REVIEW FORM Professional Staff Practitioner’s Name: _______________________________________________________ Sponsoring Physician’s Name: ______________________________________________________________ Instructions for Sponsoring Physician : The above-named practitioner has applied for Professional Staff appointment or reappointment at a Fairview entity(ies). Please complete this form to provide an evaluation of the practitioner’s current clinical competence. Thank you. 1. Complete each of the criteria below based on demonstrated performance compared to that reasonably expected of a Professional Staff at his/her level of training, experience, and background. A = Acceptable, U = Unacceptable, N.O. = Not observed. CRITERIA A U N.O. COMMENTS Basic job knowledge, competence and skill Service orientation Ethical conduct/HIPAA compliance Professional judgment Cooperativeness, ability to work with others Sense of responsibility (work timely, meet professional standards, completion of responsibilities, responsiveness to supervision) 2. The practitioner is capable of performing duties within the scope of his/her Yes No services as listed on the scope of practice. (If no, please comment below) 3. Is the overall quality of the patient care provided by the practitioner appropriate Yes No and acceptable? (If no, please comment below) Comments:______________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ RECOMMENDATION: _____ Recommend _____ Recommend with the following reservation(s)____________________________________________ _____ Do not recommend (please provide explanation in comment section) ________________________________________________________ ______________________ Sponsoring Physician Signature Date ________________________________________________________ Sponsoring Physician Name – PLEASE PRINT Return completed form to: Fairview System Credentialing Office 2344 Energy Park Dr, Ste 127 St Paul, MN 55108 c:\common\forms\cvo\Credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06 .