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Delineation of Orthopaedic Hand Surgery Privileges DELINEATION OF ORTHOPAEDIC HAND SURGERY PRIVILEGES APPLICANT’S NAME: Applicants have the burden of producing information deemed adequate by the hospital 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 residency 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 physician’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 Joint 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 Clinics 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 bone 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 osteotomies, bone grafting, internal& external fixation) 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 Infection 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 incision and drainage 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. Arthroscopy 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. Arthrodesis with or without bone grafting x 9. Arthroplasty 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
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