PAGE 1 OF 6 Fairview Health Services OBSTETRICS/GYNECOLOGY & SUBSPECIALTIES Delineation of Privileges Applicant’s Name (please print): Must be an MD/DO and have completed Threshold Criteria listed in the individual privilege sections. Completion of an ACGME or AOA approved residency and fellowship program (as applicable) is required. Current board certification by an American Board of Medical Specialties (ABMS) approved board or AOA/RCPSC approved board, or admissible for examination for certification and certification must be achieved within the time frame mandated by the appropriate board or within five (5) years after completion of residency training for those specialties where time frames are not mandated. CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity I need to the following Fairview Entity Box on Privilege 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 the Maple Grove Ambulatory Care Center in accordance with procedures available at this site. 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. COMPETENCY MEASURES DOCUMENTATION REQUIREMENTS I am a NEW APPLICANT to Fairview or Requesting Additional Privilege(s) NOT CURRENTLY HELD at a Fairview entity - Submit documentation listed below for requested privileges. Core ● Out of Training Less Than 24 Months - Requirements may be met by verification of formal training program Privileges completion in past 24 months ● Out of Training Greater Than 24 Months - Documentation of cases required for Competency Measures may be met by submitting the attached “Verification of Patient Management & Participation for Core Privileges Special Must provide one (1) of the following - training or cases must have been completed within the past 24 months: Request ● Letter from a residency or fellowship program verifying training specific to the procedure; Privileges OR ● Letter or certificate from an additional training course specific to the procedure; OR ● Documentation of specified number of cases assigned to each procedure performed (copies of operative reports, chart notes, or a list of cases performed). Documentation must include date the procedure was performed, type of procedure and where performed (e.g., name of hospital or other facility). Laser cases must also list the type of laser used. Please delete all patient identifiers such as name or medical record number from documentation to protect individual patient confidentiality. I CURRENTLY HOLD the specific privilege(s) at a Fairview entity : Sign the attestation listed on the last page of this privilege form attesting to the completion and satisfactory performance of the required number of cases for core and special request privileges as noted by each privilege. NOTE: By signing the attestation, you do not need to provide additional documentation at this time; however, Fairview will randomly audit applicants and, if selected, you will be required to provide the required documentation. Erroneous information related to the attestation may result in immediate suspension of privileges and lead to an investigation that may result in disciplinary action. Q:Central-Metro-Shares\UMMC-Business\SHAREDIR\CREDENTIAILNG DEPT\Privilege Forms\OB-GYN.doc Approved: 3/4/98; Revision approved: 6/13/01; 6/03; 6/04; 9/04; 8/06 (subcomm); 6/09 new format; 9-2011; 9/11 Bylaws Change;5/12; 8/12;5/13 PAGE 2 OF 6 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 OBSTETRICS Threshold ● Obstetrics and Gynecology residency Criteria ● Obstetrics and Gynecology board certification by American Board of Obstetrics and Gynecology Check Entity(ies) Where Privileges Requested Core Cross out privileges you do not Competency Privileges perform Measures/ Required # Hospital Entities Ambulatory Privileges include admission, evaluation, Cases in Past consultation, diagnosis, and treatment 24 Months UMMC FSH FRH FNH FLH FV Clinics of female patients of all ages presenting in any condition of pregnancy or 100 illnesses, injuries or disorders of the obstetric system. Privileges also ( Obstetric inpatient, include, but are not limited to: ambulatory &/or ● Perform history and physical exam consultative) ● Vaginal delivery ● Cerclage placement ● Breech ● Circumcision of the newborn ● Cesarean section ● Resuscitation of infant ● Vacuum extraction ● Amniocentesis and other procedures related to normal and complicated delivery ● Forceps ● Episiotomy and/or vaginal laceration repair ● Cesarean hysterectomy Competency Check Entity(ies) Where Privileges Requested Special Request Privileges Measures/ Hospital Entities Ambulatory NOTE: You may also obtain referenced additional privilege Required # form (AF) at www.fairview.org/credentialing/PrivilegeForms Cases in Past 24 Months UMMC FSH FRH FNH FLH FV Clinics Moderate and Deep Sedation - You may also obtain referenced additional privilege form (AF) at AF AF AF AF AF AF N/A www.fairview.org/credentialing/PrivilegeForms 2nd Trimester D & E 5 N/A N/A Chorionic Villus Sampling 5 N/A Fetal Umbilical Cord Blood Sampling 5 N/A Intrauterine Transfusions 5 N/A Level II Ultrasound 5 Epidural Anesthesia 5 N/A N/A N/A N/A N/A PAGE 3 OF 6 GYNECOLOGY Threshold ● Obstetrics and Gynecology residency Criteria ● Obstetrics and Gynecology board certification by American Board of Obstetrics and Gynecology Cross out privileges you do not Check Entity(ies) Where Privileges Requested Core perform Competency Privileges Privileges include admission, evaluation, Measures/ Required # Hospital Entities Ambulatory consultation, diagnosis, pre-, intra- and Cases in Past post-operative care and treatment of 24 Months UMMC FSH FRH FNH FLH FV Clinics female patients of all ages presenting with illnesses, injuries and disorders of 100 the gynecological system and nonsurgical treatment of illnesses and injuries of the ( GYN inpatient, ambulatory &/or mammary glands and urinary tract. consultative) Privileges include standard gynecological procedures involving the vulva, vagina, urethra, cervix, uterus, ovaries, and fallopian tubes as well as other pelvic procedures. Privileges also include, but are not limited to: ● Perform history & physical exam ● Appendectomy ● Repair of bladder injury ● Lymph sampling ● Repairs for pelvic relaxation and evaluation and treatment of stress urinary ● Basic pelviscopy incontinence (suspension techniques) ● Diagnostic & operative ● Advanced urogynocological diagnostic procedures hysteroscopy ● Extensive adhesiolysis ● Operative laparoscopy ● Endometrial ablation ● Enterotomy ● Reconstruction of vagina/vulva ● Oophorectomy ● Intramural myomectomy ● Cautery of endometriosis ● Infertility testing ● Hysterectomy MAPLE GROVE AMBULATORY SUGERY CENTER Threshold ● Obstetrics and Gynecology residency Criteria ● Obstetrics and Gynecology board certification by American Board of Obstetrics and Gynecology Competency Check Entity(ies) Where Privileges Requested Core Cross out privileges you do not Measures/ Privileges perform Required # Gynecology: privileges include but are Cases in Past Maple Grove Ambulatory Surgery Center 24 Months not limited to work up, diagnosis and management of patient presenting with 100 illness, injury and disorders of the ( Obstetric √ female genitourinary system, including inpatient, box for MGASC the provision of consultation and ambulatory &/or diagnostic studies. consultative) Gynecology core privileges also include diagnosis and management of gynecological diseases and procedures including, Bartholin cystectomy, biopsy (cervix, vulva, vagina, endometrium), cervical conization, dilation and curettage, hymenotomy, hysteroscopy, I&D of abscess, incidental