THANK YOU FOR APPLYING TO THE MEDICAL STAFF c.ymcdn.com/sites/ · PDF file5 Specify...

THANK YOU FOR APPLYING TO THE MEDICAL STAFF OF OPELOUSAS GENERAL HEALTH SYSTEM. ATTACHED YOU WILL FIND AN APPLICATION, CLINICAL PRIVILEGE FORM, AS WELL AS OTHER FORMS NECESSARY FOR COMPLETING THE CREDENTIALING PROCESS. PLEASE COMPLETE THE ATTACHED FORMS AND NECESSARY DOCUMENTS, AS INDICATED, AND RETURN TO ME AS SOON AS POSSIBLE. 1. Letter indicating your request and reason for seeking privileges; (please address to William “Bud”

Barrow, President and CEO. State your specialty and staff category requesting (Active, Courtesy or Consulting).

2. Print or type and sign the attached application and the clinical privilege delineation forms. BLANKS MUST BE COMPLETED. STATING “SEE CV” WILL NOT BE ACCEPTED. If additional space is needed, attach additional sheet and make reference to the question being answered.

3. Attach a copy of the following items:

a. Curriculum vitae (make sure there is an accurate account of all time from the completion of medical school).

b. Photocopy of all State Medical Licenses, ACLS, ATLS, BLS, NALS and PALS. c. Photocopy of Current State and Federal Narcotic Licenses. d. Photocopy of Current Professional Liability Insurance (Certificate of Insurance). e. Current Picture ID Photo f. Submit the names, addresses, and phone numbers of 3 references (one of which must be of the

same specialty). Do not use program directors for references, as they will automatically be requested to complete a reference questionnaire.

g. Submit the name, address and phone/fax number of the institution where Internship, Residency, and Fellowships were done. (Be sure to indicate your program director’s name)

h. List present as well as recent clinical affiliations including addresses and phone/fax numbers.

i. Health Status Statement j. Submit copies of all CME’s received within your specialty k. Copy of Annual TB Skin test or x-ray l. Proof of Citizenship, (if foreign medical school graduate) m. Copy of EFCMG Certificate (if foreign medical school graduate) n. Submit your UPIN, Medicare and Medicaid Numbers (for billing purposes) o. Use the attached form to indicate who you made arrangements with to cover your practice when you are unavailable. (Must be a member of our Medical Staff) p. Notify the Medical Staff office, in writing, of Vacation days as well as days you will not be available for your practice.

If you have any questions, please feel free to contact me at (337) 948-5168 or you may fax me at (337) 594-3895. Sincerely,

Nicole Savoy Medical Staff Coordinator

February 20, 2008

Dear Sir or Madam: Our firm provides credentialing and recredentialing verification services on behalf of _________________________________________________. All practitioners are required to complete the credentialing process prior to acceptance to the panel or medical staff. All verifications are kept strictly confidential, and we do not participate in any decision making processes. Enclosed are the following items for your review, completion and return:

• An initial credentials application • A clinical practice privileges form, if applicable • An authorization/release form • A checklist of items to include with your application

This is the only notification we will be sending to you, therefore, please complete the required documents and return them directly to us within fifteen (15) days of the date of this letter. Please contact one of our credentials analysts at (505) 343-0070, if you have any questions or require any additional information. Sincerely, Credentials Verification Services Enclosures Rev. October, 2003

Name(s) of Health Care Organization(s) to Which Application is Being Made

Date of Application:

Name: Last First Middle Other Names Used Circle all that apply and for which you are currently licensed: MD DO DDS DC DPM OD PA CNM CNP CRNA RN PT OT ST DOrienMed Acup Clin Psych Psych Assoc LMHC LPAT LADAC LISW LMSW LPC LPCC LMFT CNS/Psych CNS/Medical Spch Path Other: Specialty:

Gender: F M Citizenship: Place of Birth:

Social Security Number: Date of Birth:

State Tax ID#: Pending Federal Tax ID#: Pending Medicare #: Pending Medicaid #: Pending

Unique Physician Identification Number (UPIN): Pending Office Manager or Contact Person and telephone number:

Practice/Group Name: Effective Date:

Street Address:

City, State and Zip Code:

Telephone Number: Facsimile Number:

E-Mail Address: Answering Service Number:

Can we contact you by e-mail for credentialing correspondence? Yes No

Foreign Languages (spoken fluently by practitioner):

Foreign Languages (spoken fluently at practice):

Current Mailing Address (if different from above): Same As Above

Street Address:



Are you requesting to be credentialed as a primary care provider (PCP)? Yes No

Do you deliver babies? Yes No

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Billing Address (if different from mailing address): Same As Mailing Address

Contact Person:

Street Address:



Other Practice Locations: (Attach a separate page for additional practice locations.)

Practice Name: Street Address:



Home Address: Street Address:


Telephone Number: Pager Number:

Spouse’s Name (Optional):

Practice Associates: Call Coverage (if different):

/ / / / What are the office hours for your Practice or Group Practice? (Provide days/hours):

What provisions have been made for after hours?

PROFESSIONAL REFERENCES

Please list five professional peers with the same type of license or a higher level of licensure who are familiar with your professional performance in the past five (5) years (not including current or impending partners or associates in practice).

Name and Title: Street Address:

City, State, Country and Zip Code:

Telephone Number: Facsimile:




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Specify Internship, Residency, or Fellowship











EDUCATION Undergraduate Education:

College or University: Street Address:


Dates Attended: From To Degree Earned:

Graduate Education: (List all medical, osteopathic, dental or podiatric schools attended.)

College or University: Street Address:


Dates Attended: From To Degree Earned:

POST GRADUATE TRAINING N/A List all hospitals where you received training and attach a copy of your certificate. Disclose every residency program initiated, whether completed or not, and all completed programs. Attach a separate page, if necessary. Specialty:

Institution: Dates Attended: From

Street Address: To


Specialty:


Street Address: To


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Specialty:


Street Address: To


Teaching Appointments N/A

Institution:

Street Address:


Dates Attended: From To Department/Position:

WORK HISTORY

Please list all previous experience for the past fifteen (15) years, including months and years, listing the most recent first. Attach a separate page, if necessary. Please provide a written explanation for any gaps in work history of six (6) months or more. Organization: Dates: From To Mo/Yr Mo/Yr Street Address:


Telephone Number: Contact Person:

Organization: Dates: From To Mo/Yr Mo/Yr Street Address:


Telephone Number: Contact Person: Organization: Dates: From To Mo/Yr Mo/Yr Street Address:









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HOSPITAL AND HEALTHCARE AFFILIATIONS Are you a: Doctor of Medicine (MD)? Yes No

Doctor of Osteopathic Medicine (DO)? Yes No Certified Nurse Practitioner (CNP) as well as a primary care provider (PCP)? Yes No Certified or Licensed Nurse Midwife (CNM or LNM)? Yes No

If yes, you must: (a) Have admitting privileges at a hospital (list below) OR (b) Provide a written explanation as to the arrangements you have made with a physician to admit your

patients, along with a signed letter from that physician confirming the arrangements, and the name of the facility where your patients will be admitted.

Do you have courtesy or consulting privileges at your current primary admitting facility? Yes No If yes, do these courtesy or consulting privileges allow you to admit patients? Yes No If no, provide a written explanation as to the arrangements you have made with a physician to admit your patients, along with a signed letter from that physician confirming the arrangements, and the name of the facility where your patients will be admitted.

Please list all hospital staff membership and/or healthcare organization affiliations in the past fifteen (15) years, and your status (active, courtesy, consulting, etc.). If an institution is no longer in existence, please provide an alternative source of verification. Use a separate page, if necessary. Current Primary Admitting Facility (Hospital Name):

Street Address:



Appointment Dates: From To Type of Appointment/Status:

Privileges Assigned:

Facility Name: Street Address:




Privileges Assigned:









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MILITARY SERVICE

Branch: Dates: From To

Rank: Type of Discharge:

LICENSURE-REGISTRATION-CERTIFICATION INFORMATION

List all licenses held in all jurisdictions. Attach a separate page, if necessary.

State Professional License/Certification Number: Pending State: Issue Date: Expiration Date:




ECFMG (Educational Commission for Foreign Medical Graduates) Number (if applicable):

Date Issued: Please attach a copy of your ECFMG certificate.

Federal Drug Enforcement Administration (DEA) Registration: Pending N/A DEA Number: Expiration Date:

State Controlled Substance Registration (CSR): Pending N/A

CSR Number: Expiration Date: State:

Immigration Status: Immigration Certification Number

CLIA Number (if applicable): Approval Level: Expiration Date:

PROFESSIONAL LIABILITY INSURANCE

Do you have current liability insurance? Yes No Please list liability insurance carriers for the past fifteen (15) years. Attach a separate page, if necessary. Current Carrier: Coverage Limits:

Street Address: Current Pending


Dates Insured: From: To: Policy Number:

Carrier: Coverage Limits:

Street Address:



Carrier: Coverage Limits:

Street Address:



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SPECIALTY BOARD CERTIFICATIONS Are you Board Certified? Yes No N/A If you are not Board certified by a Board recognized by the American Board of Medical Specialties, the American Osteopathic Association, the National Commission on Certification of Physician Assistants, the American Nurses’ Credentialing Center, or the National Certification Commission, or accepted by examination in your specialty, please give a brief explanation on an attached sheet. Explain any gaps or delays in achieving Board certification by the recognized Board in your specialty area.

Certified/Recertified by the Board of:

Date Certified: Date Last Recertified: Expiration Date:

Certified/Recertified by the Board of:

Date Certified: Date Last Recertified: Expiration Date: Accepted for Examination by the Board of:

Until (Expiration Date): If not accepted, have you made application? Yes No If no, provide an explanation: Certified/Recertified by the Subspecialty Board of:

Date Certified: Date Last Recertified: Expiration Date:

Certified/Recertified by the Subspecialty Board of:

Date Certified: Date Last Recertified: Expiration Date: Accepted for Examination by the Subspecialty Board of:

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PROFESSIONAL PRACTICE QUESTIONS Please answer the following Yes or No questions. Note that “N/A” is not an acceptable response; you must answer the question. If you answer YES to any question, please give details including name, address, and telephone number of significant parties on a separate sheet of paper.

1. Has your professional liability coverage ever been terminated by action of the insurance company? Yes No

2. Have you ever been denied professional liability insurance coverage? Yes No 3. Has your professional liability carrier ever excluded any specific procedures from your

coverage? Yes No 4. Have you ever been denied membership or renewal thereof, or been subject to disciplinary

action in any professional organization? Yes No 5. Have you ever had any sanctions imposed by Medicare and/or Medicaid? Yes No 6. Have you ever been arrested, convicted of, or pled no contest to a crime or have you ever

been named as a defendant in any criminal proceedings, convicted of a felony, or subject to investigation by a governmental entity that could result in sanctions or licensure adverse actions?

Yes No

7. Have you ever been named in any formal requests for corrective actions filed by any healthcare entity where you have had an appointment (a request which could result in either formal or informal proceedings)?

Yes No

8. Have your privileges at any healthcare entity ever been voluntarily or involuntarily suspended, restricted, diminished, revoked or not renewed, except for medical records? Yes No

9. Have you ever resigned from a healthcare entity to avoid modification, suspension, or termination of privileges? Yes No

10. Has your license to practice in any jurisdiction ever been investigated, voluntarily or involuntarily limited, suspended or revoked, or are any currently held licenses pending investigation or being challenged?

Yes No

11. Have you ever been notified to appear before any licensing agency for a hearing or complaint of any nature? Yes No

12. Has your federal or state narcotics registration certificate in any jurisdiction ever been voluntarily or involuntarily limited (stipulations), suspended, revoked, restricted, or surrendered, or is it currently being challenged?

Yes No

13. Have you ever been involved in a settlement, medical malpractice claim or suit, or have you ever received written notice of intent to file such a suit? If yes, please provide the following information for each claim or suit. Please type on a separate sheet of paper for each case. • Name, age, sex of patient/claimant. • Date(s) and type of treatment and/or surgery which led to the allegations against you. • Nature of allegations in claims/suits. Specify whether a suit was ever filed. • Names of other practitioners and hospital, if any, involved in claims or suit. • Disposition or current status of claim or suit (be specific). • Name of insurance carrier defending you. • Name of defense attorney.

Yes No

14. Do you know of any reason why you cannot perform the essential duties of the clinical privileges/functions which you are requesting with or without a reasonable accommodation according to acceptable standards of professional performance and without posing a direct threat to patients?

Yes No

15. Do you use illegal drugs or have you illegally used drugs in the past five years? Yes No

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Applicant’s Attestation I, , certify that the information I have provided and the statements I have made on this application are correct, true, and complete to the best of my knowledge. I will abide by the applicable bylaws, rules and regulations, and policies and procedures of the designated health care entity. I acknowledge that I have received and reviewed a copy of the bylaws, if applicable, of the designated health care entity. I further agree that, in the event there should arise an adverse ruling with respect to my status and/or clinical privileges, I will exhaust the administrative remedies afforded by the entity’s bylaws before resorting to litigation.

Signature stamps and date stamps are not acceptable. Signature Date All applicants have the right to be informed of their application status. Application status inquiries should be directed to the appropriate health care organization. Hospital Services Corporation, a subsidiary of the New Mexico Hospitals and Health Systems Association, maintains this form, as well as a user’s mailing list, to distribute any subsequent revisions. If you have any questions about this form or if you would like to be included on the user’s list, please contact one of our credentials analysts at (505) 343-0070, or by e-mail at [email protected]. This application has been copyrighted and is intended for the sole use of our customers and approved users. Rev. October, 2003

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CHECKLIST OF DOCUMENTS TO BE RETURNED BY APPLICANT

Completed and signed application (and supplemental documents required by the healthcare organization, if applicable). Signature stamps and date stamps are not acceptable.

Completed and signed release, with all organizations to which you are applying identified in the first line of

the release. Please note that if you do not provide the authority to redisclose, you will be required to sign a separate release for any additional healthcare organizations to which you have made application. Signature stamps and date stamps are not acceptable.

Current curriculum vitae or resume including months and years for all places of employment during the

past fifteen years. Explain any gaps of six months or more during the past five years.

Copy of latest professional state license/certificate or registration. Pending

Proof of current professional liability coverage that includes the effective date, amount and type of coverage. If your coverage will be expiring within the next sixty days, please provide a copy of the renewal certificate. Pending

Copy of current state Controlled Substance Registration. If your registration will be expiring within the

next sixty days, please provide a copy of the renewal certificate. Pending

Copy of current federal DEA registration certificate. If your registration will be expiring within the next sixty days, please provide a copy of the renewal certificate. Pending

Completed privileges forms, as appropriate. For hospital appointments, please attach privileges

requested. For health plan panel membership, all MD’s and DO’s, and all Nurse Practitioners and Nurse Midwives who are primary care providers (PCP’s), must either have admitting privileges or a letter explaining the arrangements that have been made with a physician to admit patients, along with a signed letter from this physician confirming the arrangement.

Copy of ECFMG Certificate, if foreign medical graduate.

Any additional attachments required by the application.

Return to: Hospital Services Corporation

Credentials Verification Services P. O. Box 92200

Albuquerque, NM 87199-2200 Telephone: (505) 343-0070 Facsimile: (505) 346-0288

Rev. October, 2003

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HOSPITAL SERVICES CORPORATION CREDENTIALS VERIFICATION SERVICE

DESIGNATION AND AUTHORIZATION FOR RELEASE AND REDISCLOSURE OF INFORMATION (“Release”)

Authority to Release: I have applied to participate as a provider for

Print the names of all organizations to which you are applying.

and its authorized representatives (hereafter “Health Care Entity”) which has designated Hospital Services Corporation’s Credentials Verification Service (“HSC”) as their agent. I consent to complete disclosure by the recipient of this release to HSC of all relevant information pertaining to my professional qualifications, moral character, physical and mental health (hereinafter “qualifications”). I authorize the recipient to make available and/or disclose to HSC all such information in its files from any university, professional school, licensing authority, accreditation board, hospital, physician, dentist, professional society, insurance carrier, law enforcement agency, military service, or any other person or entity deemed necessary or appropriate in the investigation and processing of my application. I request and authorize the recipient to release the requested information and I expressly waive any claim of privilege or privacy with respect to the released information bearing on my admission to, retention or termination of medical staff appointment or clinical privileges. I release and discharge HSC, the Health Care Entity and the medical, dental, podiatry and ancillary staffs or panels, credentials committees, administrators, review and approval boards or committees, governing boards, whether or not designated by these titles, and their agents, servants or employees authorized by representatives and all other persons or entities supplying information to them from liability or claims of any kind or character in any way arising out of inquiries concerning me or disclosures made in good faith in connection with my application for appointment to the Health Care Entity’s Medical Staff or Provider Panel. Authority to Redisclose: Unless I have denied authority by initialing here , I authorize the Health Care Entity, the Health Care Entity’s Authorized Representatives, and HSC to redisclose information concerning my qualifications, or credentials and privileges to third parties who have a need to know the information (1) based upon state or federal laws or regulations, or (2) pursuant to any health care provider agreement to which I am or will be a party and in which I have an interest as an individual health care provider. This Release does not authorize HSC to disclose information about my qualifications to any claimant. If a claimant requests information from HSC about me or if a subpoena duces tecum is served upon HSC seeking information about me, which is in HSC’s possession, I understand I will be notified immediately. If I direct HSC to resist the subpoena, I hereby agree to indemnify and hold harmless HSC, its officers, directors, employees and agents for all attorney fees, costs, fines, and expenses incurred in resisting the subpoena at my request. This authorization is limited to the acquisition and disclosure of information required by state or federal law, and information which is acquired or disclosed pursuant to activities protected by the state’s Review Organizational Immunity Act and the Health Care Quality Improvement Act of 1986. A photocopy of this Designation and Authorization for release and redisclosure of information shall be considered by the recipient to be a signed original, as long as it is transmitted to the recipient by HSC and is received within five years of its date. The certain definitions used in this Release and set forth on its reverse side are incorporated by reference. I understand that I may withdraw or modify this authorization at any time in writing by submitting a written request to HSC. PHOTOCOPY BOTH PAGES OF THIS FORM.

Signature stamps and date stamps are not acceptable. Applicant Signature Printed Name Date

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DEFINITIONS of terms used in this Designation and Authorization for Release and Redisclosure of information. “Health Care Entity” is the Health Care Entity on the front of this form. The “Health Care Entity’s Authorized Representatives” include any management or quality assurance companies hired by the Health Care Entity or HSC; the Health Care Entity’s Board, staffs, committees, CEO, administrator medical director or other employees of the Health Care Entity whose performance of duties requires access to information about my qualifications; consultants whose contract with the Health Care Entity requires access to information about my qualifications; any independent credentialing services including HSC; and the Health Care Entity’s attorneys and insurers. “Credentials and Privileges” means all information regarding my qualifications, my standing with the Health Care Entity, and my right to provide healthcare services at or through the Healthcare Entity. It also includes any limitations imposed upon my right to provide healthcare services and any final disciplinary action taken by the Health Care Entity with regard to my provision of healthcare services at or through the Healthcare Entity. “Credentialing Verification Service” is the service operated by Hospital Services Corporation. HSC may be required as a condition of certification by the National Committee for Quality Assurance (NCQA) to permit audits of HSC’s system. The person providing this Release acknowledges that these audits are conducted solely for the purpose of certifying the credentialing verification service, and all information utilized by the NCQA is treated as confidential. “Claimant” means any person, guardian, or personal representative who is asserting an administrative or legal claim against the person providing this release based in whole or in part upon allegations that the person providing this release has violated any state or federal law or regulation or has committed medical malpractice. “Medical Staff or Provider Panel” is to be interpreted broadly to include any group of healthcare providers howsoever designated, who are authorized to provide healthcare services to patients, insureds, beneficiaries, members, or enrollees of a healthcare plan. “Third Parties who have a need to know” include, but are not limited to governmental agencies and boards; organizations, associations, partnerships, corporations; other hospitals and clinics; managed care organizations, Independent Practice Associations (“IPA’s”), Managed Service Organizations (“MSO’s”), Physician Hospital Organizations (“PHO’s”), Preferred Provider Organizations (“PPO’s”), Health Maintenance Organizations (“HMO’s”), medical foundations, insurance underwriters, employer or employee sponsored ERISA health plans, health care alliances, or others with whom I am negotiating a health care provider agreement, presently have a health care provider agreement or with whom the Health Care Entity identified on the front page of this authorization (or the Health Care Entity’s Authorized Representatives) is negotiating a health care provider agreement or has health care provider agreement in which I have or will acquire an interest. Rev. October, 2003

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ACKNOWLEDGEMENT

OF

RECEIPT OF NOTICE

I, the undersigned, acknowledge that I have received and read the following “Notice to Physicians” by this hospital:

“Notice to Physicians: Medicare and Champus payment to hospitals is based in part on each patient’s principal and secondary diagnosis and the major procedures performed on the patient, as attested to by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies or conceals essential information required for payment of Federal funds, may be subject ot fine, imprisonment or civil penalty under applicable Federal laws.”

Date Signature

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Please complete the following signature card as you would when signing in the hospital patient medical record. Thank you.

Signature

Print Name

Abbreviated Signature

Initials

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OPELOUSAS GENERAL HOSPITAL

Cardiology

Cardiovascular Disease is a subspecialty of Internal Medicine. This subspecialty has in recent years divided into several separate divisions, some with there own certifying Boards. On the first page of this application, you will find the minimal formal training required to be eligible to request clinical privileges in clinical cardiology. The subsequent sections of this application list the additional special procedures in the sub-divisions of cardiovascular disease for which you may wish to apply. E.g. (Cardiac catheterization and angiography, percutaneous transluminal coronary angioplasty (PTCA), peripheral and visceral angiography, peripheral vascular intervention, nuclear cardiology, transesophageal echocardiography, pacemakers, implantable cardiac defibrillators and fellows/trainees). The qualifications for each of these sections are listed and proof of demonstrated competency must be provided. A final section is included for supplemental procedures, which are not core to cardiology. All applicants may be subject to proctoring of any special procedures requested. IN ORDER TO BE ELIGIBLE TO REQUEST CLINICAL PRIVILEGES, THE FOLLOWING MINIMAL THRESHOLD CRITERIA MUST BE MET: Basic Education: MD or DO Minimal Formal Training: Satisfaction of one of the following:

1. Board Certification in Cardiovascular disease by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine. or

2. Board certification in Internal Medicine with active participation in the process leading to the Board Certification in Cardiovascular disease. This is the definition of Board Eligible. or

3. Successful completion of an accredited Cardiology Fellowship, with letters to attest to competency from the director of the Fellowship program and two cardiologist who have direct knowledge of the applications skill and training.

Required Previous Experience: The successful applicant must demonstrate that he/she has performed at least

50 cardiology consult procedures in the past 12 months (INITIAL APPOINTMENT ONLY).

Reappointment: When applying for reappointment to the Medical Staff, the applicant must

demonstrate that he/she has maintained current clinical competency based on numbers of procedures performed compared to those required for initial appointment. Numbers of procedures will include all procedures performed by the applicant during the course of his/her practice, whether in this hospital, another hospital, or physician’s office. Numbers of procedures, while important, are not the sole criteria for reappointment. Also reviewed will be that physician’s outcomes of patient care, based upon the unbiased, objective results of this hospital’s quality assurance mechanisms.

Core Cardiology Privileges Core Cardiology, Non-Invasive: Admit, evaluate, diagnose and provide treatment and consultative services to adults presenting with diseases of the heart, lungs, and blood vessels and an appropriate level of internal medicine. Privileges include ACLS, interpretation of EKG’s and holter monitors;use

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of thrombolytic agents; electrical and chemical cardioversion using IV sedation (see moderate conscious sedation protocol/privilege); treadmill testing, tilt table testing; including stress echocardiography and radionucleotide studies; echocardiography interpretation including transesophageal echocardiography interpretation (note: 15 hours, every 3 years, of echo specific CME are recommended for OGH to maintain its echo lab accreditation with ICAEL).

___ Re quested ___Granted

Core Cardiology, Invasive: Privileges include insertion and management of central venous, pulmonary

artery catheters and central lines; temporary trans-venous pacemaker placement; pericardiocentesis; intra-aortic balloon pump; and insertion of femoral arterial sheath.


CARDIAC CATHETERIZATION AND ANGIOGRAPHY Qualifications:

1. Core cardiology privileges. 2. Documentation of training and competency in cardiac catheterization and angiography. Letter of

reference must come from the Fellowship Director department, Chief of Cardiology Catheterization laboratory

3. The applicant must be able to demonstrate that he/she has completed a minimum of 150 cardiac catheterizations during the past 2 years.

4. New requests are made final after being proctored for at least (3) cases by an experienced cardiologist with current privileges in cardiac catheterization, maintaining at least (75) cases per year as the primary operator.

5. When volume falls below (75) cases per year as the primary operator for two years in a row, the physician must show evidence of continued CME in invasive cardiology along with success and complication rates equal to or better than the average of the clinical section.

Privileges:

1. Cardiac catheterization and angiography. 2. Venography of the cardiac structures


PTCA/STENT QUALIFICATIONS AND PRIVILEGES Qualifications:

1. CORE Cardiology privileges. 2. Cardiac catheterization and angiography privileges. 3. Satisfaction of one of the following:

a. Completion of a fellowship training program during which a minimum of (150) PTCA’s are done, with evidence of (75) procedures as the primary operator and certification of competency by the training director. Physicians who are more than 2 years away from the completion of their cardiology fellowship but engaged in an active hospital practice must show evidence of (150) procedures and 75 as the primary operator in the last twelve months or (1000) lifetime procedures as the primary operator, with acceptable results and current competency. or

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b. If a physician has not obtained training and experience during a cardiology fellowship, but is actively engaged in PTCA at another hospital, he/she must show that they have done (150) PTCA procedures in the last 12 months, with evidence of (150) procedures with 75 as the primary operator and certification of competency by the training director. Physicians who are more than 2 years away from the completion of their cardiology fellowship must show evidence of (75) procedures as the primary operator in the last twelve months or (1000) lifetime procedures as the primary operator, with acceptable results and current competency. OR

c. If a physician is making a new request for this privilege, not previously trained in this procedure, he/she must perform under the direct supervision of an appropriately trained physician, (100) PTCA procedures, with evidence of (75) procedures as the primary operator and certification of competency.

4. When volume falls below (75) PTCA’s for two years in a row, the physician must show evidence of current CME in interventional cardiology along with success and complication rates equal to or better than the clinical section average.

Privileges:

Requested Granted Procedures Non-complex PTCA/stent; EF > 30%, creatinine < 2.0, single vessel PTCA. Complex PTCA’s; EF < 30%, creatinine >2.0, multiple vessel PTCA Primary or rescue angioplasty in patients presenting with acute Myocardial

infarction. Atherectomy with documented training on this specific device Thrombectomy with documented training on this specific device. Retrieval of intravascular foreign bodies May participate in investigational protocol if physician meets criteria of the lead

investigator and, if appropriate, such study is approved by Opelousas General Hospital’s Investigational Review Board (IRB).

Insertion of inferior vena cava filter

PERIPHERAL AND VISCERAL ANGIOGRAPHY Qualifications:

1. Core cardiology privileges. 2. Satisfaction of one of the following:

a. Completion of a fellowship training program during which a minimum of (100) peripheral and visceral diagnostic angiograms are done, with evidence of (75) procedures as the primary operator and certification of competency by the training director. Physicians who are more than 2 years away from the completion of their cardiology fellowship but engaged in an active hospital practice must show evidence of (100) procedures with 25 as the primary operator in the last twelve months or (250) lifetime procedures as the primary operator, with acceptable results and current competency. or

b. If a physician has not obtained training and experience during a cardiology fellowship, but is actively engaged in peripheral and visceral angiography at another hospital, he/she must show that they have done (100) peripheral and visceral diagnostic angiograms, with evidence of (75) procedures as the primary operator and certification of competency by the training director.

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Physicians who are more than 2 years away from the completion of their cardiology fellowship must show evidence of (100) procedures with 25 as the primary operator in the last twelve months or (250) lifetime procedures as the primary operator, with acceptable results and current competency. or

c. If a physician is making a new request for this privilege, not previously trained in this procedure, he/she must perform under the direct supervision of an appropriately trained physician, (100) peripheral and visceral diagnostic angiograms, with evidence of (75) procedures as the primary operator and certification of competency.

3. When the volume falls below (25) angiography procedures for two years in a row, the physician must show evidence of current CME in peripheral angiography, along with success and complication rate better than or equal to the clinical section average.

Privileges: Perform and interpret peripheral and visceral angiography, including pulmonary angiography, Venography of the arms and legs and loopagram/fistulagram.


CAROTID ANGIOPLASTY

Qualifications: 1. Physicians who have participated in carotid angioplasty/stent trials and have performed a

minimum of 50 carotid angioplasty and stent placement. 2. Indications for carotid angioplasty and stenting are limited to:

a. Restenosis following carotid endarterectomy b. Non surgical candidates:

⇒ High surgical risk (based on carotid anatomy and patients comorbidity) ⇒ Following tracheostomy ⇒ Previous radiation therapy to the neck


Peripheral Intervention Qualifications and Privileges Qualifications: 1. Core cardiology privileges. 2. Peripheral and visceral angiography privileges. 3. Satisfaction of one of the following

a. Completion of a fellowship training program during which the applicant must have performed a minimum of (100) peripheral angioplasty procedures, with evidence of (75) procedures as the primary operator under the supervision of an experienced arteriographer and certification of competency by the training director. Physicians who are more than 2 years away from the completion of their cardiology fellowship must show evidence of (100) procedures with 25 as the primary operator in the last twelve months or (250) lifetime procedures as the primary operator, with acceptable results and current competency. or

b. If a physician has not obtained training and experience during a cardiology fellowship, but is actively engaged in peripheral and visceral angioplasty at another hospital, he/she must show that they have performed a minimum of (100) peripheral angioplasty procedures, with evidence of (75) procedures as the primary operator under the supervision of an experienced arteriographer and certification of competency by the training director. Physicians who are more than 2 years away from the completion of their cardiology fellowship must show evidence of (100) procedures with 25 as the primary operator in the last twelve months or (250) lifetime procedures as the primary operator, with acceptable results and current competency.

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c. If a physician has not obtained the above required experience in a vascular lab, he/she can qualify by: ⇒ Show evidence of current CME in peripheral intervention and ⇒ Successful completion of two courses in peripheral transluminal angioplasty and stent

placement with live case demonstrations and ⇒ Performance of a minimum of (100) peripheral angioplasty procedures, with evidence of

(75%) procedures as the primary operator and ⇒ Discuss selection criteria, techniques, complications, and their treatment, rescue procedures

for failed procedures, concurrent use of thrombolytics, and surgical alternative treatments with the director of the Cardiac Catheterization Lab who has peripheral interventional privileges; and who is willing to proctor the physician for at least (10) cases, after which a statement must be signed indicating the physician is competent to perform these procedures and

⇒ Complete at least (25) cases within twelve months with acceptable success and complication rate.

4. When the volume falls below (25) peripheral angioplasty procedures for two years in a row, the physician must show evidence of current CME in peripheral angiography, along with success and complication rate better than or equal to the clinical section average.

Privileges: Place a checkmark in the space for each privilege requested

Requested Granted Procedures PTA/stent of the peripheral vessels Placement of catheters and infusion of thrombolytics in peripheral arteries or

veins. Mechanical thrombectomy/embolectomy with documented training

on a specific device. May participate in investigational protocol if physician meets criteria

of the lead investigator and, if appropriate, such study is approved by Opelousas General Hospital’s Investigational Review Board (IRB).

Fluroscopy Insertion of inferior vena cava filter

All new peripheral interventional procedures or devices will first be discussed at an appropriate clinical committee. The discussion will include case selection, complications and their management, qualifications to participate, training, alternative treatments, informed consent of patients, and follow-up of patients. This committee will then inform the credentials committee, in writing, or appear in person to explain the procedure and privileges requested for the specific physician before the first procedure. Statistics on new procedures will be reviewed for at least 6 months at the clinical committee level.

NUCLEAR CARDIOLOGY

Qualifications:

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CORE Cardiology privileges. Board certified or eligible in nuclear cardiology OR meet criteria to have name added to nuclear license at Opelousas General Hospital.

Participation in exclusive contract arrangements of Opelousas General Hospital for Nuclear Cardiology.

Privileges: 1. Perform pharmacologic and stress radionucleotide studies. 2. Interpretation of nuclear studies at Opelousas General Hospital


TRANSESOPHAGEAL ECHOCARDIOGRAPHY Qualifications:

1. CORE Cardiology privileges. 2. Satisfactorily performed at least 20 Transesophageal echocardiogram (TEE) procedures during

his/her fellowship or in the past 2 years. 3. If new to this procedure, applicants must attend at least 2 formal TEE programs attaining a

minimum of 24 category 1 CME hours AND such courses must include both didactic and laboratory experience, including at least 10 hands-on TEE procedures.

Privileges: Performance and interpretation of transesophageal echocardiograms.


PACEMAKERS

Qualifiacations: 15 pacemaker implants If new to this procedure, the applicant must attend, two pacemaker training courses which include both didactic and laboratory experience including at at least 5 hands on pacemaker implants. The physician will also be required to perform 12 implants under a proctor with a letter from the proctor upon completion of training.


FELLOWS/TRAINEES Qualifications: CORE cardiology privileges. For peripheral vascular interventional training, applicants must have completed a formal Residency or Fellowship in cardiology surgery, vascular surgery or radiology. Privileges: Performance of cardiac catheterization, angiography, cardiac and peripheral interventional procedures (pacemaker insertions) under the direct supervision of a fully credentialed cardiologist with these privileges at Opelousas General Hospital.


Cardiology - Supplemental Privileges For any special procedure/test/therapy listed below, proof of demonstrated competency must be provided. For applicants just out of residency, this may be a printout of activity from your residency

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signed by the residency director. Other applicants may provide an activity list from another accredited hospital or a certificate of completion of a training program. Additional proof of competency may be requested at the discretion of the appropriate medical director or Medical Executive Committee. The applicant may be subject to proctoring of any special procedures.

Requested Granted Procedures Thoracentesis Insertion of Quinton Catheter Ventilator Management – Basic (Management of at least 6 cases in the prior 2

years is needed for re-credentialing) Conscious Sedation – moderate (see special credentialing criteria) Biventricular pacemaker implants Defibrilator implants (pacemaker privileges required and first 5 cases must be

proctored I understand that in making this request, I am bound by Opelousas General Health Systeml’s Medical Staff Bylaws and policies. I hereby stipulate that I meet the threshold for each request.

Health Status

I am able to perform all the procedures for which I have requested privileges, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a threat to patients. Date Requested Date Approved

Physician Signature

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