appendix Sample Application for Gynecologic Pr∣VILEGES ^24

1. Name:______________________________________________________

2. Department to which I am applying:______________________________

3. Other department(s) in which

clinical privileges are held or sought:_____________________________

4.

5. Emergency situations:

I also understand

(a) that the privileges are being requested for regular use in my practice;

(b) that it is not necessary to request emergency clinical privileges;

(c) that an emergency is deemed to exist whenever serious per­manent harm or aggravation of injury or disease is immi­nent, or the life of a patient is in immediate danger, and any delay in administering treatment could add danger;

(d) that in such emergency, when better alternative sources of care are not reasonably available given the patient’s condi­tion, I am authorized and will be assisted to do everything possible to save the patient’s life or to save the patient from serious harm to the degree permitted by my license but regardless of department affiliation or privileges;

(e) and that if I provide services to a patient in an emergency, I am obligated to use appropriate consultative assistance when available and to arrange, when it is my responsibil­ity, for appropriate follow-up care.

General Provisions

Basis for Granting Privileges

1. Applicants requesting clinical privileges must demonstrate satisfac­tory training, experience, and current competence for the privileges being requested and must agree to comply with the provisions con­tained in the medical staff bylaws.

2. Each applicant requesting privileges in the department of obstetrics and gynecology should be required to present his or her application and a list of recent cases for review by the department chief. (For phy­sicians who have just completed an ob-gyn residency program, the list could be the senior resident case list.) When family physicians or nurse-midwives request privileges, an equivalent list of recently man­aged cases, representing the full range of privileges being requested, also must be submitted.

Provisional Period

1. All new appointees to the department of obstetrics and gynecology must undergo a minimum provisional period of no less than 12 months. The practitioner should have admitted a minimum number of cases to the hospital, completed an equivalent number of surgical procedures, or both, as defined by the institution.

2. At the chair’s discretion, any additional documentation deemed necessary to assess an applicant’s competency in specific procedures during the provisional period may be requested. This documentation may include evidence of specific education or training in a procedure either during residency training or through postresidency courses.

3. At the conclusion of their provisional period, those individuals who did not meet the minimum criteria stipulated under Number 1, or those who requested other than active staff status, should provide the chair with a detailed listing of each case completed within the depart­ment as well as the description, scope, and breadth of their practice at other institutions. In addition to the hospital’s quality improvement review, the department chair also may request information from other institutions where the individual practices to assess overall competency for the procedure(s) requested.

4. Those individuals requesting privileges for a new procedure must have successfully completed their initial provisional period and have been appointed to the medical staff without restriction.

They also should submit evidence they have completed an educational or training program in the specific procedure either in a residency program or through postgraduate residency training. In addition, each applicant should submit a letter from the director of a residency program stating that he or she is competent in the respective procedure and has completed the appropriate training.

Individuals requesting privileges for a new procedure must be deemed competent to perform the procedure by an individual currently creden­tialed for that procedure in the department. However, if this is the first time these privileges have been requested within the department, arrange­ments should be made to ensure that the applicant is adequately evaluated before granting full, unrestricted privileges. In general, a minimum number of cases with preceptorship or observation, as defined by the institution, are required before full, unrestricted privileges can be granted for a new procedure.

New, Untried, Unproven, or Experimental Procedures and Treatment Modalities and Instrumentation

Experimental drugs, procedures, or other therapies or tests may be admin­istered or performed only after approval of protocols involved by the com­mittee responsible for the institutional review board function. Any other new, untried, unproven, or experimental procedure or treatment modality or instrumentation may be performed or used only after the regular cre­dentialing process has been completed, and the privilege to perform or use said procedure or treatment modality or instrument has been granted to an individual practitioner. For the purposes of this paragraph, a new, untried, unproven, or experimental procedure or treatment modality or instrumen­tation is one that is not generalizable from an established procedure or treatment modality or instrumentation that involves the same or similar skills, the same or similar instrumentation and technique, the same or similar complications, or the same or similar indications as the established procedure or treatment modality or instrumentation.