KALEIDA HEALTH

Name: ______Date: ______

INTERNAL MEDICINE SUBSPECIALTY – GASTROENTEROLOGY

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.

Minimal requirements: 1. Successful completion of an ACGME accredited, AOA, Royal College of Physicians and Surgeons of Canada, or an ACGME equivalent Gastroenterology fellowship program. 2. Board certification in Gastroenterology. If not board certified, applicant will be given two (2) years from date of initial appointment to obtain certification in this specialty. *Maintenance of board certification is mandatory for all providers who have achieved this status.*

Moderate/Conscious Sedation privileges are required for Level II and Level III Privileges. Please attach a copy of your current Conscious Sedation training certificate. If you do not have Moderate/Conscious Sedation privileges, please request the privilege as listed on the Internal Medicine Delineation of Privileges or you must invite a Kaleida health Anesthesiologist to participate in the procedure.

GASTROENTEROLOGY – LEVEL I Not With Following PHYSICIAN Requirements** CORE PRIVILEGES REQUEST Granted Granted (Provide Details) * Consultation GASTROENTEROLOGY - Volume Volume With Following for for PHYSICIAN Requirements** LEVEL II PRIVILEGES (Case list initial Reappoint REQUEST Not (Provide Details) = Volume requirement) privilege ment Granted Granted Competence in all procedures (exclusive of (within past * ) requires the ability to perform 3 years) appropriate therapeutic maneuvers at the same setting. The performance of diagnostic procedures without the ability to treat all lesions reasonably expected to be encountered during is not supported. Moderate/Conscious Sedation privileges are required and are part of the Internal Medicine Delineation of Privileges. General Procedures 5 5 with Polypectomy (min 30 140 140 out of the 140 must be Polypectomy) EGD 130 40 Endoscopic Control of Hemorrhage: - Non-variceal 25 5 - Variceal 20 5 20 10 10 10 ERCP 200 50 - biliary or pancreatic stent 10 10 placement -cyst /drain placement 5 5 - lithotripsy 10 5 - sphincterotomy 40 20 Esophageal manometry 5 5 Esophageal prosthesis placement 10 5

IM-Gastroenterology 4-2021

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GASTROENTEROLOGY Volume Volume With Following - LEVEL II PRIVILEGES For for PHYSICIAN Not Requirements** continued Moderate/Conscious Initial reappoint REQUEST Granted Granted* (Provide Details) Sedation privileges are required and Privilege ment are part of the Internal Medicine (within past Delineation of Privileges. 3 years) EUS (Endoscopic Ultrasound) -mucosal tumors 75 35 -pancreaticobiliary 75 35 -submucosal abnormalities 40 20 Fine Needle Aspiration 75 35 Flexible Sigmoidoscopy 30 5 PEG 15 10 Percutaneous biopsy 10 10 PH monitoring 5 5 Pneumatic esophageal dilation 5 5

GASTROENTEROLOGY Volume Volume With Following - LEVEL III For for PHYSICIAN Not Requirements** PRIVILEGES (Case list = Initial reappoint REQUEST Granted Granted* (Provide Details) Volume requirement) Privilege ment Moderate/Conscious Sedation (within past 3 years) privileges are required and are part of the Internal Medicine Delineation of Privileges. Apollo Overstitch/Endostitch ^ 3 ^Requires EGD privilege and certificate of supported training, (i.e. vendor) Endoscopic Mucosal Resection 10 15 (EMR) Requires certificate of supported training Endoscopic Submucosal *5 5 Dissection (ESD) Requires ASG Certificate of training and *5 proctored cases OVESCO clip device *3 2 Requires EGD and Colonoscopy privileges and *certificate of supported training in *3 cases, (i.e. vendor) Radio Frequency Ablation 10 5 (BARRX) Requires EGD privilege, and certificate of supported training, (i.e. vendor or volume) Spyglass *5 5 Requires ERCP privilege, certificate of supported training and *2 proctored cases

IM-Gastroenterology 4-2021

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GASTROENTEROLOGY Volume Volume With Following - LEVEL III For for PHYSICIAN Not Requirements** PRIVILEGES continued Initial reappoint REQUEST Granted Granted* (Provide Details) Moderate/Conscious Sedation Privilege ment privileges are required and are (within past 3 years) part of the Internal Medicine Delineation of Privileges. STRETTA 3 3 Requires EGD privilege and certificate of supported training, (i.e. vendor) TIF – Transoral Incisionless ^ 2 Fundoplication ^Requires EGD privilege and certificate of supported training, (i.e. vendor)

Endoscopic laser - At 10 ^^ Initial appointment, applicant must submit a case list of ten cases, with at least three (3) of those cases being proctored in accordance with successful completion of the required Kaleida Health LASER Safety and Training Course. ^^The LASER Safety and Training Course certification must be renewed every two (2) years thereafter.

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:______

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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 (42 U.S.C. 11101 et seq.)

/ / Signature of Applicant Date Signature of Chief of Service Date

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

IM-Gastroenterology 4-2021