July 28, 2021
TO: Quality Professional Services Committee
FROM: Brandon Boesch, D.O., Alameda Health System Chief of Staff Catherine Pyun, D.O., Alameda Hospital Chief of Staff
SUBJECT: Agenda Item: B4
Meeting Date: July 28, 2021
Item Description: Medical Staff Specialty Privilege Forms
COMMITTEE ACTION: Approval of revised Medical Staff Privilege Form
Background: The specialty privilege form(s) listed in the analysis section are either new privilege forms or revised privileges forms, both designed to offer a systematic approach for care across our facilities (AHS, SLH, AH) as applicable.
Analysis: Whether new or revised, the Medical Staff privilege forms are updated through a succinct process using best practice and clinical evidence.
Prior Board Action: n/a
Board Action Requested: Approval of revised privilege form that offer a system-wide approach for privileges that support patient care at AHS.
Revised Privilege Form(s) for AHS and AH: • Emergency Medicine Multifacility • Neurology Multifacility • Teleneurology Multifacility
Revised Privilege Form(s) for AHS: • Alameda Hospital Medical Privileges
Fiscal Impact: n/a
Budgeted/Authorized: n/a
Estimated Cost Savings: n/a
Strategic Plan Pillar: Access, Quality, Experience
AHS Emergency Medicine Multifacility Privileges Delineation of Privileges
Applicant's Name:
1. 2. 3. 4.
Required Qualifications Membership Meet all requirements for medical staff membership
Education/Training For initial applicants, effective January 1, 2020, completion of an ACGME or AOA accredited residency training program in Emergency Medicine. OR Current certification in Emergency Medicine by the American Board of Emergency Medicine or the American Osteopathic Board of Emergency Medicine.
Continuing Education Applicant must have 25 CME credits per year (waived for applicants who have completed residency training during the previous 24 months) OR Applicant must be active in MOC (maintenance of certification) program in emergency medicine
Certification For all new applicants who will be appointed on/after January 1, 2017, current certification or board eligibility in Emergency Medicine by the American Board of Emergency Medicine or in Emergency Medicine by the American Osteopathic Board of Emergency Medicine.
Clinical Experience (Initial) Applicant must demonstrate active practice as an Emergency Physician (minimum of 500 cases worked in the prior two year period). Waived for applicants who completed training during the previous year.
Clinical Experience Applicant must demonstrate active practice as an Emergency Physician (minimum of 300 cases) (Reappointment) representative of the scope and complexity of privileges requested during the previous 24 months.
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 1 of 6 Primary Privileges in AHS Emergency Medicine Multifacility Privileges
Description: Immediate recognition, evaluation, care, stabilization and disposition of a generally diversified population of patients in response to acute illness and injury. Focus on the immediate decision making and action necessary to prevent death or any further disability.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Perform history and physical examination Attend, evaluate, diagnose and initially treat patients who present to the emergency department with any symptom, illness, injury or condition, and provide services necessary to ameliorate minor illnesses or injuries; stabilize patients with major illnesses or injuries and assess all patients to determine if additional care is necessary. Inpatient admission Admit and attend adolescents (14-21) years of age Procedures Diagnostic procedures including arthrocentesis; lumbar puncture; slit lamp examination; tonometry; pulse oximetry; arterial blood gas sampling and analysis; EKG; preliminary X-ray interpretation; and occult blood testing. Techniques utilized to stabilize the airway including use of airway adjuncts, rapid sequence intubation with paralytic agent, image-guided and video assisted laryngoscopy Cricothyrotomy Mechanical ventilation - all modes Skeletal procedures including stabilization of fractures and dislocations; immobilization techniques; reduction techniques; backboard and cervical immobilization techniques. Excision of thrombosed hemorrhoids Foreign body removal Gastric lavage Jejunostomy and gastrostomy tube replacement Wound management and closure including management of burns, nail removal, I&D abscess and evacuation of hematoma Laryngoscopy, control of epistaxis, posterior packing and chemical cautery Emergent delivery of newborns; Doppler fetal heart tones; pelvic exam; perimortem C-Section; and removal of IUD Thoracentesis Thoracostomy Pericardiocentesis Emergent thoracotomy Paracentesis and lavage Suprapubic tap and catheterization Urethral dilation Lateral canthotomy Vascular access including arterial catheter insertion; central venous access; venous cutdown
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 2 of 6 Intraosseous infusion Thrombolytic administration Insertion of temporary pacemaker or use of external pacemaker and elective cardioversion
FPPE Requirements AHS Core AH
Ten (10) retrospective case reviews that are representative the scope and complexity of privileges requested.
Special Privilege Cluster: Emergency Focused Ultrasound
Description: Investigational ultrasound for trauma or other indication.
Qualifications Education/Training Documentation of training and experience during residency OR Emergency medicine physicians who did not receive training during residency should demonstrate at a minimum 25 proctored ultrasounds per primary indication or a minimum of 150 ultrasounds for general emergency ultrasound privileges OR Physicians who completed training greater than 5 years ago must provide evidence of ongoing clinical practice. OR Letter from Emergency Department Ultrasound Director certifying training and experience.
Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must provide evidence of ongoing clinical practice representative of the scope of (Reappointment) privileges requested during the past 24 months.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Perform and interpret emergent, focused or investigational ultrasound
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 3 of 6 FPPE Requirements AHS Core AH
Five (5) retrospective case reviews
Privilege Cluster: Stroke Care
Qualifications Education/Training For recent graduates of Emergency Medicine Residency program, physician must have completed at least a 1-month Neurology rotation during Emergency Medicine residency or must attest to supervised management of acute stroke patients (10 cases) during residency.
Certification NIH Stroke Scale Certification at initial appointment
Clinical Experience (Initial) Applicant must attest to providing (5 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must have provided clinical services (5 cases) representative of the scope and (Reappointment) complexity of privileges requested during the past 24 months
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Stroke care Thrombolytic Therapy - Standard Protocol
FPPE Requirements AHS Core AH
Ten (10) retrospective case reviews that are representative of the scope and complexity of the privileges requested.
Transesophageal Echocardiography (TEE)
Description: Directly visualized, focused TEE in cardiac arrest patients with tracheal intubation.
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 4 of 6 Qualifications Education/Training Providers seeking credentialing in transesophageal echocardiography of cardiac arrest applications should have completed training and met competency standards in transthoracic echocardiography and: Completed a minimum of 2-4 hours of TEE-specific CME or didactics; AND Performed a minimum of 10 cardiologist proctored TEE examinations (including probe insertion) on live patients and simulation models; AND Completed a standardized assessment by a credentialed TEE provider
Clinical Experience (Initial) 10 procedures performed during previous 12 months (waived for applicants who completed training within the previous year)
Clinical Experience 10 procedures performed per year (average over 2 years) (Reappointment)
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Focused Transesophageal Echocardiography (TEE) including probe placement, image acquisition and interpretation.
FPPE Requirements AHS Core AH
Retrospective review of 3 cases
Acknowledgment of Applicant
I have requested only those privileges for which by education, training, current experience, and demonstrated competency I believe that I am competent to perform and that I wish to exercise at Alameda Health System hospital(s) and I understand that:
A. In exercising any clinical privileges granted, I am constrained by applicable 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.
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 5 of 6 Practitioner's Signature Date
Department/Service Chair Recommendation - Privileges
I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):
Privilege Condition/Modification/Deletion/Explanation
Department/Service Chair Recommendation - FPPE Requirements
Signature of Department/Service Chair or Designee Date
Published: 7/6/2021 1:12:56 PM AHS Emergency Medicine Multifacility Privileges Page 6 of 6 Neurology - Multifacility Delineation of Privileges
Applicant's Name:
1. 2. 3. 4.
Required Qualifications Membership Meet all requirements for medical staff membership.
Education/Training Completion of an ACGME accredited Residency training program in Neurology.
Continuing Education Applicant must have 25 Category I CME credits per year (waived for applicants who have completed residency training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in Neurology.
Certification Current certification in Neurology by the American Board of Psychiatry and Neurology.
Clinical Experience (Initial) Applicant must provide documentation of provision of neurology services (50 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must have provided clinical services (25 cases) representative of the scope and (Reappointment) complexity of privileges requested during the past 24 months
Published: 7/6/2021 1:31:00 PM Neurology - Multifacility Page 1 of 5 Core Privileges in Neurology
Description: Diagnosis, treatment and consultation related to disease or impaired function of the brain, spinal cord, peripheral nerves, muscles and autonomic nervous system, as well as the blood vessels that relate to these structures.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Admit to inpatient or appropriate level of care Perform history and physical examination Evaluate, diagnose, provide consultation, medically manage and treat patients with acquired or congenital disease, disorders or impaired function of the neurological system. Procedures EEG/Video monitoring Performance and interpretation of basic neurophysiology tests including EEG and evoked potential studies (auditory, visual and somatosensory). Performance and interpretation of EMG, nerve conduction and autonomic testing Perform muscle or nerve biopsy
FPPE Requirements AHS Core AH
Five retrospective case reviews that are representative of the scope and complexity of privileges requested.
Privilege Cluster: Stroke Care
Qualifications Education/Training For recent graduates of a Neurology Residency program.
Certification NIH Stroke Scale Certification at initial appointment
Clinical Experience (Initial) Applicant must attest to providing (5 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must have provided clinical services (5 cases) representative of the scope and (Reappointment) complexity of privileges requested during the past 24 months
Published: 7/6/2021 1:31:00 PM Neurology - Multifacility Page 2 of 5 Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Stroke care Thrombolytic Therapy - Standard Protocol
FPPE Requirements AHS Core AH
Two retrospective case reviews that are representative of the privileges requested.
Moderate (Procedural) Sedation
Description: Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness. No interventions are required to maintain a patent airway, spontaneous ventilation is adequate and cardiovascular function is maintained.
Qualifications Education/Training The applicant must provide evidence of training and supervised experience during residency and/or fellowship OR if training occurred greater than 1 year ago the applicant must provide evidence of ongoing clinical practice.
Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must provide documentation of provision of clinical services representative of the scope (Reappointment) and complexity of the privileges requested during the previous 24 months.
Additional Qualifications Current ACLS certification AND Annual completion of AHS Procedural Sedation Competency.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Moderate Sedation Published: 7/6/2021 1:31:00 PM Neurology - Multifacility Page 3 of 5 FPPE Requirements AHS Core AH
Two retrospective case reviews of administration of moderate sedation.
Acknowledgment of Applicant
I have requested only those privileges for which by education, training, current experience, and demonstrated competency I believe that I am competent to perform and that I wish to exercise at Alameda Health System hospital(s) and I understand that:
A. In exercising any clinical privileges granted, I am constrained by applicable 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.
Practitioner's Signature Date
Department Chair Recommendation - Privileges
I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):
Privilege Condition/Modification/Deletion/Explanation
Published: 7/6/2021 1:31:00 PM Neurology - Multifacility Page 4 of 5 Department Chair Recommendation - FPPE Requirements
Signature of Chief/Designee Date
Signature of Department Chair/Designee Date
Published: 7/6/2021 1:31:00 PM Neurology - Multifacility Page 5 of 5 Teleneurology Multifacility Delineation of Privileges
Applicant's Name:
1. 2.
Required Qualifications Basic Education M.D. or D.O.
Education/Training Completion of an ACGME or AOA accredited Residency training program in Neurology.
Continuing Education Applicant must have 25 Category I CME credits per year (waived for applicants who have completed residency training during the previous 24 months). OR Applicant must be active in the MOC (maintenance of certification) program in Neurology.
Certification Current certification in Neurology by the American Board of Psychiatry and Neurology or in Neurology by the American Osteopathic Board of Neurology and Psychiatry.
Clinical Experience (Initial) Applicant must provide documentation of provision of neurology services (50 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must have provided clinical services (25 cases) representative of the scope and (Reappointment) complexity of privileges requested during the past 24 months.
Published: 7/6/2021 1:35:45 PM Teleneurology Multifacility Page 1 of 5 TELEMEDICINE- NEUROLOGY
Description: To be eligible to request Telemedicine-Neurology privileges, the following additional criteria must be met:
Qualifications Education/Training Completion of an ACGME or AOA accredited Residency training program in Neurology.
Certification Current certification in Neurology by the American Board of Psychiatry and Neurology or in Neurology by the American Osteopathic Board of Neurology and Psychiatry.
Clinical Experience (Initial Documentation of clinical activity within the scope of privileges requested. Appointment and Reappointment)
Continuing Education Applicant must have 25 CME credits per year (waived for applicants who have completed (Reappointment) residency training during the previous 24 months). CME shall be related to privileges requested and include 8 hours focused on Cerebrovascular Disease.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges Evaluation and treatment of patients 18 years of age or older presenting with emergent neurological illnesses including, but not limited to, acute stroke, stroke, and threatened stroke (TIA or Transient Ischemic Attack). Obtain history and physical Conducting a thorough and timely neurological examination via two-way audio- and two-way video- conferencing technology Reviewing and personally interpreting relevant brain imaging studies Interpretation of the results of other relevant diagnostic tests to formulate a differential diagnosis and to recommend an evaluation and management plan Evaluation and treatment of patients 18 years of age or older, in an inpatient or outpatient setting, presenting with neurological illnesses
FPPE/Proctoring Requirements AHS Core AH
Five (5) retrospective case reviews that are representative of the scope and complexity of privileges requested.
EEG INTERPRETATION
Published: 7/6/2021 1:35:45 PM Teleneurology Multifacility Page 2 of 5 Description: To be eligible to request EEG privileges, the following additional criteria must be met:
Qualifications Education and Training Successful completion of a postgraduate training program in which clinical neurophysiology was included and current subspecialty certification in clinical neurophysiology by the ABPN or equivalent board with EEG emphasis. OR
Clinical Experience (Initial) Demonstration of equivalent training and competence and the performance of a sufficient volume of diagnostic EEGs during the past 24 months or completion of training in the past 12 months.
Clinical Experience Demonstrated current competence and evidence of the performance of a sufficient volume of (Reappointment) EEG's reflective of the privileges requested in the past 24 months based on the results of ongoing professional practice evaluation and outcomes.
Request Request all privileges listed below. AHS Core AH
- Currently granted privileges EEG Interpretation
FPPE/Proctoring Requirements AHS Core AH
Five (5) retrospective case reviews that are representative of the scope and complexity of privileges requested.
STROKE CARE
Qualifications Education/Training Completion of an ACGME or AOA accredited Residency training program in Neurology.
Continuing Education Eight (8) hours of annual stroke education units per year (waived for applicants who have completed residency training during the previous 24 months).
Certification NIH Stroke Scale Certification at initial appointment
Clinical Experience (Initial) Applicant must attest to providing (5 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Request Request all privileges listed below. Published: 7/6/2021 1:35:45 PM Teleneurology Multifacility Page 3 of 5 s Date
FPPE/Proctoring Requirements - Currently granted privileges Stroke care - Standard Protocol Thrombolytic Therapy Two (2) retrospective case reviews that are representative of the privileges requested. Two (2) retrospective case reviews that AH AH
AHS Core AHS Core Department Chair Recommendation - Privileges Acknowledgment of Applicant Published: 7/6/2021 1:35:45 PM Teleneurology Multifacility Page 4 of 5 Medical staff rely upon the credentialing verifications made by the distant-site telemedicine entity when making Medical staff rely upon the credentialing verifications made by the distant-site telemedicine its written agreement with the distant-site recommendations on privileges for the individual distant-site physicians through telemedicine entity. Practitioner's Signature B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my action granted to me is waived in an emergency situation and in such situation my B. Any restriction on the clinical privileges A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rules I am constrained by applicable Hospital and Medical Staff policies and A. In exercising any clinical privileges granted, to the particular situation. applicable generally and any applicable I have requested only those privileges for which by education, training, current experience, and demonstrated competency I which by education, training, current experience, and demonstrated competency I have requested only those privileges for that: and that I wish to exercise at Alameda Health System hospital(s) and I understand believe that I am competent to perform are governed by the applicable section of the Medical Staff Bylaws or related documents. are governed by the applicable section Privilege Condition/Modification/Deletion/Explanation
Department Chair Recommendation - FPPE Requirements
Signature of Chief/Designee Date
Signature of Department Chair/Designee Date
Published: 7/6/2021 1:35:45 PM Teleneurology Multifacility Page 5 of 5 Alameda Hospital - Medical Privileges Application for Medical Privileges
Applicant's Name:
1. 2. 3. 4.
Required Qualifications Membership Meet all requirements for medical staff membership
Education/Training For initial applicants, effective January 1, 2020, completion of an ACGME or AOA accredited residency program in Internal Medicine.
Continuing Education Applicant must have 25 Category I CME credits per year directly related to the practice of internal medicine (waived for applicants who have completed training during the previous 24 months). OR Applicant must be active in the MOC program in internal medicine or applicable specialty by the relevant American Board of Medical Specialties or American Osteopathic Board.
Certification Current certification or board eligibility in the examination process leading to certification in internal medicine or applicable specialty by the relevant American Board of Medical Specialties or American Osteopathic Board.
Clinical Experience (Initial) Applicant must provide documentation of provision of internal medicine (50 cases) representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must provide documentation of provision of clinical services (50 cases) representative of (Reappointment) the scope and complexity of privileges requested during the previous 24 months.
Additional Qualifications NIH Stroke Scale Certification at initial appointment (stroke privileges only) Radiological Safety - Fluoroscopy Criteria: Practitioner must submit evidence with this application of a current California Fluoroscopy Operator's Permit.
Published: 7/6/2021 1:40:06 PM Alameda Hospital - Medical Privileges Page 1 of 5 Privilege Specialties
Description: Provision of general medical/primary care managing both common and complex illnesses.
Request Request all privileges listed below. Svc Uncheck any privileges that you do not want to request. Chair Rec
Please indicate below your medical specialty area(s) for which you will be requesting privileges. Allergy/Immunology Dermatology Endocrine/Metabolic Infectious Diseases Internal Medicine Nephrology Pulmonary Medicine
General Privileges
Description: Provision of general medical/primary care managing both common and complex illnesses.
Request Request all privileges listed below. Svc Uncheck any privileges that you do not want to request. Chair Rec
Admitting/Attending Privileges Diagnosis & Management of internal medicine inpatients and outpatients Stroke Care-with criteria requirements
Proctoring/FPPE Requirements First two (2) medical admissions and/or (2) outpatient clinical visits
Procedural Privileges
Request Request all privileges listed below. Svc Uncheck any privileges that you do not want to request. Chair Rec
Lumbar Puncture Thoracentesis Paracentesis CVP Peripheral Subclavian/Int. Jug. Central IV Catheter Fermoral Line Central IV Catheter
Published: 7/6/2021 1:40:06 PM Alameda Hospital - Medical Privileges Page 2 of 5 Arthrocentesis History and Physical Thrombolytic Therapy (standard protocol) IV Conscious Sedation PULMONARY PROCEDURES Bronchoscopy with biopsy Bronchoscopy (therapeutic) Transthoracic needle biopsy Thoracostomy: Percutaneous Thoracostomy: Open Pulmonary function tests complete with report Spirometry with report NEPHROLOGY PROCEDURES Hemodialysis: Acute Hemodialysis: Chronic Peritoneal dialysis Renal biopsy Continuous AV-Hemofiltration Continuous AV-Hemofiltration w/dialysis DERMATOLOGY PROCEDURES Skin biopsy Resection of skin lesions Dermabrasion Simple cryotherapy Skin biopsy interpretation ENDOCRINE/METABOLISM PROCEDURES TPN Fine needle biopsy thyroid Continuous AV-Hemofiltration Continuous AV-Hemofiltration with dialysis URGENT/EMERGENCY CARE Laceration repair not involving tendons, major vessels, or major nerves Incision and Drainage
Proctoring/FPPE Requirements Five (5) retrospective case reviews that are representative of the scope and complexity of privileges requested.
Moderate (Procedural) Sedation
Qualifications Education/Training The applicant must provide evidence of training and supervised experience during residency and/or fellowship OR if training occurred greater than 1 year ago the applicant must provide evidence of ongoing clinical practice.
Clinical Experience (Initial) Applicant must provide documentation of provision of clinical services representative of the scope and complexity of the privileges requested during the previous year (waived for applicants who completed training during the previous year).
Clinical Experience Applicant must provide documentation of provision of clinical services representative of the scope and complexity of the privileges requested during the previous 24 months. Published: 7/6/2021 1:40:06 PM Alameda Hospital - Medical Privileges Page 3 of 5 Additional Qualifications Current ACLS certification AND Annual completion of AHS Procedural Sedation Competency.
Request Request all privileges listed below. Svc Uncheck any privileges that you do not want to request. Chair Rec
Moderate Sedation Moderate Sedation
Proctoring/FPPE Requirements Three (3) retrospective case reviews of administration of moderate sedation.
Acknowledgment of Applicant
I have requested only those privileges for which, by education, training, current experience and demonstrated performance, I am qualified to perform, and that I wish to exercise at Alameda Hospital. I acknowledge that my professional liability insurance extends to all privileges I have requested.
In the case of an emergency, any individual who is a member of the Medical Staff or who has been granted clinical/surgical privileges is permitted to do everything possible within the scope of his/her license, to save a patient's life or to save a patient from serious harm, regardless of staff status or privileges granted.
Practitioner's Signature Date
Service Committee Chair Recommendation - Privileges
I have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):
Privilege Condition/Modification/Deletion/Explanation
Published: 7/6/2021 1:40:06 PM Alameda Hospital - Medical Privileges Page 4 of 5 Service Committee Chair Recommendation - FPPE Requirements
Signature of Service Committee Chair/Designee Date
Published: 7/6/2021 1:40:06 PM Alameda Hospital - Medical Privileges Page 5 of 5