DELINEATION OF ORTHOPAEDIC PRIVILEGES

APPLICANT’S NAME: Applicants have the burden of producing information deemed adequate by the for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any concerns related to qualifications for requested privileges. 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.

Orthopaedic Hand Surgery Core – To be eligible for orthopaedic hand surgery privileges the applicant must meet the following education and training requirements:

 Successful completion of an ACGME or AOA accredited in orthopaedic surgery, or equivalent as outlined in the Medical/Dental Staff Bylaws ; AND

 Successful completion of a fellowship in hand surgery, or equivalent as outlined in the Medical/Dental Staff Bylaws; AND

 Current certification by an approved American Board of Medical Specialties certifying body in orthopaedic hand surgery or American Osteopathic Association in orthopaedic hand surgery, or an equivalent Board as defined in the Medical/Dental Staff Bylaws; or must become certified in the ’s appropriate specialty or sub- specialty area within the time frame outlined in the Medical/Dental Staff Bylaws; or, meet the criteria and be approved for a board certification waiver as outlined in the Medical/Dental Staff Bylaws.

Initial Competency Requirements: Each initial applicant who completed their post graduate training greater than five (5) years ago shall submit documentation of at least 10 orthopaedic hand surgery cases performed within the past 12 months at a Commission accredited institution. For applicant’s who completed their post graduate training within the past 5 years, Children’s will obtain a clinical evaluation from the applicable post graduate training program director.

Focused Review: The assigned proctor will perform retrospective chart reviews and/or direct observations on, at a minimum, 5 patient encounters (representative of the entire core), for all newly granted clinical privileges. For applicants who currently hold privileges at a Children’s Health facility, the Division Director may assign a tiered approach to FPPE in accordance to M/D Staff Policy #3.05 – Focused Professional Practice Evaluations (FPPE). If a new applicant is unable to provide documentation that meets the initial case log criteria, the Division Director shall recommend an additional level of FPPE in accordance to the FPPE policy.

Reappointment Criteria for Orthopaedic Hand Surgery Core: Each practitioner must be able to provide documentation, either internal documentation from Children’s Health or documentation from another Joint Commission accredited institution, of at least 10 orthopedic hand surgery cases from within the past 24 months, where the applicant functioned as the primary surgeon. If an applicant is unable to provide documentation that meets this criterion the Division Director will recommend an additional level of FPPE in accordance to M/D Staff Policy #3.05 – Focused Professional Practice Evaluations.

Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 1 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY

DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES

APPLICANT’S NAME:

Core Privileges in Request ORTHOPAEDIC HAND SURGERY Privileges to admit, evaluate, conduct histories and physicals, diagnose, consult and provide non-surgical and surgical  care to patients meeting the appropriate age criteria as defined in Administrative Policy #2.06 – Age Criteria for Inpatient Admissions and Operative Procedures with conditions, illnesses or injuries of the musculoskeletal system and perform routine procedures (see attached list). Orthopaedic Hand Surgery Privileges will include but are not limited to the following: Please note if you do not want to request a privilege that is automatically included in the core, submit this request in writing. Any additional procedures requested that are not listed below must be submitted in writing to the Division Director of Orthopaedic Surgery for consideration. Please note, an X in the box below indicates that this procedure is offered at that location. If you are granted Core privileges, you will have privileges to perform the procedures in the Core at all locations that it is offered. Dallas Pavilion Surgery Outpatient General Procedures Campus Center 1. Biopsy of skin x x x 2. Biopsy of muscle x x 3. Biopsy of nerve x x 4. Biopsy of lymph node x x 5. Biopsy of x x 6. Removal of implants x x x Dallas Pavilion Surgery Outpatient Trauma Campus Center Clinics 1. Closed Treatment of Fractures x x x 2. Open or percutaneous treatment of fractures (including open or closed or pathologic fractures) with internal, external or intramedullary fixation including x x fractures with soft tissue loss or neurovascular compromise 3. Management of tendon injuries. Includes exploration and/or repair with or without grafts (auto, allo, xeno and synthetic) of skin, muscle, tendon, ligament, x x nerve and vascular injuries 4. Management of ligament injuries. Includes exploration and/or repair with or without grafts (auto, allo, xeno and synthetic) of skin, muscle, tendon, ligament, x x nerve and vascular injuries 5. Management of nerve injuries. Includes exploration and/or repair with or without grafts (auto, allo, xeno and synthetic) of skin, muscle, tendon, ligament, x x nerve and vascular injuries 6. Management of vascular injuries. Includes exploration and/or repair with or without grafts (auto, allo, xeno and synthetic) of skin, muscle, tendon, ligament, x nerve and vascular injuries 7. Management of compartment syndrome x 8. Management of other soft issue injuries with or without grafts x x 9. Management of delayed and/or nonunions (includes , , internal& ) x x

Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 2 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY

DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES

APPLICANT’S NAME: Dallas Pavilion Surgery Outpatient Campus Center Clinics 1. Osteoarticular infection (including septic arthritis and osteomyelitis) treated medically x x x 2. Osteoarticular infection (including septic arthritis and osteomyelitis) treated with aspiration x x x 3. Osteoarticular infection (including septic arthritis and osteomyelitis) treated with biopsy x x 4. Osteoarticular infection (including septic arthritis and osteomyelitis) treated with x x Reconstruction - Upper Extremities Dallas Pavilion Surgery Outpatient Shoulder Campus Center Clinics 1. Manipulation for the treatment of congenital or acquired dislocation, subluxation, instability, contracture or deformity x x x 2. Tendon transfers for the treatment of congenital or acquired dislocation, subluxation, instability, contracture or deformity x x 3. for the treatment of congenital or acquired dislocation, subluxation, instability, contracture or deformity x x 4. Other soft tissue procedures for the treatment of congenital or acquired dislocation, subluxation, instability, contracture or deformity x x 5. Osteotomies of the scapula with or without internal or external fixation for the treatment of congenital or acquired contracture or deformity x 6. Osteotomies of the clavicle with or without internal, external or intramedullary fixation for the treatment of congenital or acquired contracture or deformity x x 7. Osteotomies of the humerus with or without internal, external or intramedullary fixation for the treatment of congenital or acquired contracture or x x deformity 8. with or without bone grafting x 9. x 10. Amputation for the treatment of congenital or acquired dislocation, subluxation, instability, contracture or deformity x Dallas Pavilion Surgery Outpatient Elbow Campus Center Clinics 1. Manipulation for the treatment of congenital or acquired contracture or deformity x x x 2. Tendon transfers for the treatment of congenital or acquired contracture or deformity x x 3. Arthroscopy for the treatment of congenital or acquired contracture or deformity x x 4. Other soft tissue procedures for the treatment of congenital or acquired contracture or deformity x x 5. Osteotomies of the ulna with or without internal, external or intramedullary fixation for the treatment of congenital or acquired contracture or deformity x x 6. Osteotomies of the radius with or without internal, external or intramedullary fixation for the treatment of congenital or acquired contracture or deformity x x Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 3 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY

DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES

APPLICANT’S NAME: 7. Arthrodesis with or without bone grafting x 8. Arthroplasty x 9. Amputation for the treatment of congenital or acquired contracture or deformity x Dallas Pavilion Surgery Outpatient Forearm/ Campus Center Clinics 1. Manipulation for the treatment of congenital or acquired contracture or deformity x x x 2. Tendon transfers for the treatment of congenital or acquired contracture or deformity x x 3. Arthroscopy for the treatment of congenital or acquired contracture or deformity x x 4. Other soft tissue procedures for the treatment of congenital or acquired contracture or deformity x x 5. Carpectomies – partial or complete x x 6. Arthrodesis with or without bone grafting x x 7. Arthroplasty x x 8. Amputation for the treatment of congenital or acquired contracture or deformity x Dallas Pavilion Surgery Outpatient Hand Campus Center Clinics 1. Manipulation for the treatment of congenital or acquired contracture or deformity x x x 2. Tendon transfers for the treatment of congenital or acquired contracture or deformity x x 3. Arthroscopy for the treatment of congenital or acquired contracture or deformity x x 4. Other soft tissue procedures for the treatment of congenital or acquired contracture or deformity x x 5. Osteotomies of the metacarpals with or without internal, external or intrameduallary fixation for the treatment of congenital or acquired contracture or x x deformity 6. Osteotomies of the phalanges with or without internal, external or intrameduallary fixation for the treatment of congenital or acquired contracture or x x deformity 7. Arthrodesis of the PIP with or without bone grafting x x 8. Arthrodesis of the MCP Joints with or without bone grafting x x 9. Arthrodesis of the DIP Joints with or without bone grafting x x 10. Excision of a digit x x x 11. Pollicization of a digit x 12. Arthroplasty x x 13. Amputation for the treatment of congenital or acquired contracture or x deformity

Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 4 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY

DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES

APPLICANT’S NAME: MODERATE SEDATION PRIVILEGES – To be eligible for sedation privileges, the applicant must meet the following qualifications:  Be privileged in a clinical division at Children’s Medical Center OR requesting privileges in a clinical division at Children’s Medical Center AND  Provide proof and maintain current advanced life support certification (PALS, APLS, or NRP). Note: *Attending who are privileged and board certified or eligible in , oral and maxillofacial surgery, pediatric critical care, neonatal-perinatal , pediatric , otolaryngology, or pediatric are exempt from maintaining this certification, however must have had one of these certifications within 5 years prior to their initial request for sedation privileges; AND  Successfully complete the Children’s Health Sedation Module Post-Test (upon initial credentialing and at reappointment) with a final score of 80% or greater.

Request MODERATE SEDATION Defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful  response. No interventions are required to maintain a patient airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Practitioners requesting this level of sedation privileges also have privileges to manage inadvertent deep sedation, which requires managing a compromised airway including provision of adequate oxygenation and ventilation. Additional requirements for moderate sedation:

Initial Competency Requirements: Case log documentation, either from their training program or from another Joint Commission institution, of at least 5 cases from within the past 12 months demonstrating the provision of moderate sedation.

Focused Review: The assigned proctor will perform retrospective chart reviews on 3 cases for all providers newly granted clinical privileges in moderate sedation. If an applicant is unable to provide documentation that meets the initial case log criteria, the Division Director shall recommend an additional level of FPPE in accordance to M/D Staff Policy #3.05 – Focused Professional Practice Evaluations.

Reappointment Criteria: Case log documentation, either internal documentation from Children’s or documentation from another Joint Commission accredited institution, of at least 10 cases from within the past 24 months demonstrating the provision of moderate sedation. If an applicant is unable to provide documentation that meets this criterion the Division Director will recommend an additional level of FPPE in accordance to M/D Staff Policy #3.05 – Focused Professional Practice Evaluations. By my signature, I hereby attest that I have read and will comply with the current Children’s Health sedation policies as outlined in Clinical Practice Policy 4.65 – Moderate Sedation Administration and Management for Procedures.

Applicant’s Signature Date

If Applicable NO YES Exceptions to above recommended by Director, Sedation Program:  

Exceptions recommended:

REVIEWED/APPROVED BY: Medical Director of Institutional Procedural Sedation – Courtney Derderian, MD

Signature: Date:

Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 5 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY

DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES

APPLICANT’S NAME:

I hereby request clinical privileges in the specialty and/or fields as shown on this form and attest that I have only requested those privileges for which by education, training and current experience I am qualified to perform and wish to exercise at Children’s Health. I further understand that:  Privileges requested may differ from those finally approved;  Completion of this form, at the present time, does not preclude me from requesting additional privileges in the future;  I shall be authorized to treat, in a life-threatening emergency, any medical disease or perform any medically appropriate or surgical procedure to save life or limb or alleviate suffering of the patient that I am attending until proper consultation can be obtained;  Staff appointments and clinical privileges will be made in conformance with the existing Medical/Dental Staff Bylaws, Rules and Regulations and policies and procedures of the Medical/Dental Staff and shall be evaluated biennially;  Staff privileges may also be evaluated as deemed necessary based on concerns identified through the peer review process, or during the ongoing professional practice or focused professional practice evaluation processes;  Failure to obtain board certification as outlined above in the timeframe required by the Medical/Dental Staff Bylaws, or non- compliance with Children’s policies, Medical/Dental Staff Bylaws, Rules and Regulations, or Code of Ethical Conduct may constitute grounds for non-renewal or restriction/limitation of clinical privileges.

By my signature, I agree to be bound by the Medical/Dental Staff Bylaws, Rules and Regulations, and the policies and procedures of Children’s Health. I understand that non-compliance with any of these documents may constitute grounds for termination or restriction of privileges.

Applicant’s Signature Date

APPROVALS If Applicable NO YES Exceptions to above recommended by Division Director:  

Exceptions recommended:

REVIEWED/APPROVED BY: Division Director, Pediatric Orthopaedic Surgery – Karl Rathjen, MD

Signature: Date: Surgeon-In-Chief – Robert Foglia, MD

Signature: Date:

Applicants Initials:______Children’s Medical Center Dallas – Delineation of Orthopaedic Hand Surgery Privileges Page 6 of 6 Revised: 7/19/16 Approved by the BOD: 8/16/16; 2/5/10 Sedation revised: 9/2015 Sedation approved by the BOD: 10/6/15 PRIVILEGED AND CONFIDENTIAL *** FOR CREDENTIALING PURPOSES ONLY