HomeMy WebLinkAboutMINUTES - 04222014 - C.32RECOMMENDATION(S):
Approve new medical staff appointments, advancements, additional privileges, changes to primary department and
resignations as recommend by the Medical Staff Executive Committee at their March 17, 2014 meeting, and by the
Health Services Director.
FISCAL IMPACT:
None.
BACKGROUND:
The Joint Commission on Accreditation of Healthcare Organizations has requested that evidence of Board of
Supervisors approval for each Medical Staff member will be placed in his or her Credentials File. The above
recommendations for appointment/reappointment were reviewed by the Credentials Committee and approved by the
Medical Executive Committee.
CONSEQUENCE OF NEGATIVE ACTION:
If this action is not approved, Contra Costa Regional Medical and Contra Costa Health Centers' medical staff would
not be appropriately credentialed and not be in compliance with the Joint Commission on Accreditation of Healthcare
Organizations.
CHILDREN'S IMPACT STATEMENT:
Not applicable.
APPROVE OTHER
RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE
Action of Board On: 04/22/2014 APPROVED AS RECOMMENDED OTHER
Clerks Notes:
VOTE OF SUPERVISORS
AYE:John Gioia, District I Supervisor
Candace Andersen, District II
Supervisor
Mary N. Piepho, District III
Supervisor
Karen Mitchoff, District IV
Supervisor
Federal D. Glover, District V
Supervisor
Contact: Anna Roth, 370-5101
I hereby certify that this is a true and correct copy of an action taken and entered on the minutes of the Board
of Supervisors on the date shown.
ATTESTED: April 22, 2014
David Twa, County Administrator and Clerk of the Board of Supervisors
By: June McHuen, Deputy
cc: T Scott, C Rucker, David Goldstein, M.D.
C. 32
To:Board of Supervisors
From:William Walker, M.D., Health Services Director
Date:April 22, 2014
Contra
Costa
County
Subject:Medical Staff Appointments and Reappointments – March 2014
ATTACHMENTS
Recommendations
Attachment 1
Attachment 2
Attachment 3
MEC Recommendations – March 2014 Page 1
A. New Medical Staff Members
Dwaine Bobo, MD Anesthesia
Luke Bi, MD Internal Medicine
Catherine Do, DDS Dental
Oron Frenkel, MD Emergency Medicine
Scott Josephson, MD Internal Medicine (UCSF Tele)
Fritz Leidig, MD Emergency Medicine
Lilllian Pan, DO Emergency Medicine
Joan Roux, MD Pediatrics
Danny Wu, MD Internal Medicine
B. Advance to Non-Provisional
Joanna Chin, MD Pediatrics
Charleen Lee Kim, MD Surgery
John Lipson, MD Family Medicine
Michell Orengo-McFarlane, MD Family Medicine
Arash Mohebati, MD Surgery
Karen Peterson, MD Psychiatry/Psychology
Julie Pham, DO Family Medicine
Jeffrey Pierce, MD Family Medicine
Robert Pollard, MD Emergency Medicine
Cynthia Williams, CNM Ob/Gyn
C. Request for Additional Privileges
Brandy Danison, NP Internal Medicine
Mary Moreno, MD Family Medicine
D. Request to change Primary Department
Name Current Department New Department
Stephanie Phillips, NP Family Medicine Internal Medicine
E. Biennial Reappointments
Charles Berletti, MD Ob/Gyn C
David Carey, MD Family Medicine A
Katharine Goheen, MD Family Medicine A
George Lee, MD Anesthesia A
Richard McIlroy III, MD Family Medicine A
MEC Recommendations – March 2014 Page 2
Howard Min, MD Internal Medicine C
Saunaz Sarvi, DDS Dental A
Chiyo Shidara, DDS Dental A
Thomas Eusterbrock, MD Pediatrics C
Brian Hopkins, MD Surgery C
Ben Kim, DDs Dental A
Akindele Kolade, MD Psychiatry/Psychology A
*Ronel Lewis, MD Psychiatry/Psychology C
Joanna Mandell, MD Family Medicine A
Arash Mohebati, MD Surgery P/C
John Pabers, MD Emergency Department C
*Annelies Rainer, MD Psychiatry/Psychology C
Jeana Radosevich, MD Family Medicine A
Sonika Shah, MD Internal Medicine A
Mark Smith, MD Family Medicine A
Daniel Sobel, MD Emergency Medicine A
Barbara Swarzenski, MD Psychiatry/Psychology A
*No Hospital affiliations, requires MEC waiver.
F. Biennial Renewal of Privileges
Jessica Oqvist, LM Ob/Gyn AFF
G. Voluntary Resignations
Rachel Bratlie, MD Psychiatry/Psychology
Zenaida Mendoza, MD Family Medicine
Emily Newfield, MD Ob/Gyn
Holly Stewart, Md Psychiatry/Psychology
H. New Privileges for NP’s and Midwives
Attachments (3)
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 1 of 8
12/2013 Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet
Inpatient Privileges
FAM
5 Inpatient histories and physicals.
D NP CA Lic. N/A N/A
C NP CA Lic 30
6
months
in the
last 2
years
FAM
6
General medical care of psychiatric
inpatients.
D NP CA Lic. N/A N/A
C NP CA Lic 30
6
months
in the
last 2
years
FAM
8
General medical care of oncology
inpatients.
D NP CA Lic. N/A N/A
C NP CA Lic. 30
6
months
in the
last 2
years
FAM
9
Chemotherapy prescribing privileges
(inpatient and outpatient) implementing a
plan of chemo or hormonal therapy, which
has been determined by a physician.
D NP CA Lic. N/A N/A
U
NP CA Lic.
oncology
certification
2 yrs. in
oncology
clinic and
50
supervise
d order
sets
10
cases in
last 2
yrs.
EME
10
Bedside testing in the ED (POCT)
Stool Guiac Gastrocult U NP CA Lic. 10 N/A
OBG
34
Caring for, and discharging uncomplicated
post-partum patients (for providers without
delivery privileges).
C NP CA Lic. N/A N/A
U NP CA Lic 50
20 in
last
2 yrs.
PED
11
Inpatient uncomplicated newborn care (e.g.
normal term newborn and those with
indirect bilirubin <15).
C NP CA Lic. N/A N/A
U NP CA Lic 20
3 cases
in last 2
yrs
MED
General inpatient care including health care D NP CA lic. N/A N/A
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 2 of 8
12/2013 Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet 3 maintenance, excluding all cases where
expected improvement is not soon
apparent or when specialized therapeutic or
diagnostic techniques are needed.
14 years - 65 years old
C NP CA lic. 30
6 mos.
In
last 2
yrs.
MED
4
General inpatient care including health care
maintenance as above...
> 50 years old
D NP CA lic.. N/A N/A
C NP CA lic. 30
6 mos.
in
last 2
yrs.
OBG
22
Diagnostic D&C, incomplete or missed
abortion
D
NP CA lic N/A N/A
C NP CA lic 10 N/A
U NP CA lic 20
1 cases
in last 4
yrs.
OBG
23 Abortion first trimester
D NP CA lic N/A N/A
C NP CA lic 10 N/A
U
NP CA Lic &
unrestricted
privileges for
D&C
20
8 cases
in last 2
yrs.
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 3 of 8
12/2013
MED
7
Complex inpatient medical care. Providers
with these privileges are expected to have
training and/or experience comparable to
specialty training, although not necessarily
at the level of the subspecialist. Such
providers may act as consultants to others
and may, in turn, be expected to request
consultation when:
a. Diagnosis and/or management remain
in doubt over an unduly long period of
time, especially in the presence of a
life-threatening illness;
b. Unexpected complications arise which
are outside this level of competence;
c. Specialized treatment or procedures
are contemplated with which they are
not familiar.
14 years - 65 years old
D NP CA lic. N/A N/A
C NP CA lic. 30
1 year
in last 2
yrs.
MED
8
Complex inpatient medical care as above...
> 50 years old
D NP CA lic. N/A N/A
C NP CA lic. 30
1 year
in last 2
yrs.
MED
9 Lumbar puncture.
D NP CA lic. N/A N/A
U NP CA lic. 5 N/A
SGN
4 Thoracentesis.
D NP CA lic. N/A N/A
U NP CA lic. 5
1 case
in last 4
yrs.
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 4 of 8
12/2013
SGN
5
Paracentesis
D NP CA lic. N/A N/A
U NP CA lic. 5
1 case
in last 4
yrs.
ANE
3
Moderate (Conscious) sedation
Does NOT include use of ketamine or
propofol
D NP CA lic.
N/A N/A
C
NP CA lic.
and Airway
Management
skills (ANE
11
endotracheal
intubation or
inservice)
10
1 case
in last
2 yrs.
12
Minor laceration repair, finger and toenail
trephination, I&D of abscesses, hematomas,
acutely thrombosed hemorrhoids,
debridement of burns, digital blocks,
injections of tendon sheaths, ligaments,
trigger points and bursae, and superficial
foreign body removal
D
NP CA lic.
N/A
N/A
U
NP CA lic.
30
10
cases in
last 2
yrs.
13
Basic diagnosis and management of general
surgical problems: Anoscopy, needle drain
cysts, I&D abscesses, excision of moles and
sebacious cysts, initial management acute
abdomen
D
NP CA lic.
N/A
N/A
U NP CA lic. 20
10
cases in
2 years
14
Fine Needle Aspiration
D
NP CA lic.
N/A
N/A
U
NP CA lic.
5
2 cases
in 4
years
15
Surgical assisting
D NP Ca Lic N/A N/A
U NP Ca Lic 20
10
cases in
2 years
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 5 of 8
12/2013
16
Orthopedics: Circumferential casting,
reduction of uncomplicated dislocations
D NP Ca Lic
N/A
N/A
C NP Ca Lic 5
2 cases
in last 4
yrs.
U NP Ca Lic 10
5 cases
in the
last 4
years
SGN
6 Joint Aspiration.
D NP CA lic. N/A N/A
U NP CA lic. 5
1 case
in last 4
yrs.
MED
10 Bone Marrow Aspiration.
D NP CA lic. N/A N/A
U NP CA lic 5
1 case
in last 4
yrs.
MED
13 Percutaneous liver biopsy
D NP CA lic. N/A N/A
C NP CA lic. 20
5 cases
in last 4
yrs.
MED
18 Flexible Sigmoidoscopy.
D NP CA lic. N/A N/A
U NP CA lic. 15
5 cases
in last 4
yrs.
ANE
11 Endotracheal Intubation
D NP CA lic. N/A N/A
U NP CA lic. 10
2 cases
in last 4
yrs.
MED
23 Elective Cardioversion. D NP CA lic. N/A N/A
SGN
9 Chest tube insertion
D NP CA lic. N/A N/A
U NP CA lic. 5
2 cases
in
last 2
yrs.
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 6 of 8
12/2013
MED
26
EKG interpretation (official report)
D NP CA lic N/A N/A
C NP CA lic
100
directly
supervise
d cases
100
cases in
the past
2 yrs.
MED
28 Exercise Stress Test.
D NP CA lic N/A N/A
C NP CA lic
15 directly
supervise
d cases
15
cases in
last 2
yrs.
MED
30 Pulmonary Function interpretation.
D NP CA lic. N/A N/A
U NP CA lic. 50
20
cases in
last 4
yrs.
CC
2
Ventilator management of critically ill
patients
D NP CA lic. N/A N/A
C NP CA lic. 10
5 cases
in last 4
yrs.
CC
3
Hemodynamic management of critically
ill patients requiring vasopressors
D NP CA lic. N/A N/A
C NP CA lic. 10
5 cases
in last 4
yrs.
CC
5
Adult arterial line placement, monitoring
and management.
D NP CA lic. N/A N/A
C NP CA lic. 10
5 cases
in last 4
yrs.
CC
6
Adult central venous placement,
monitoring and management
D NP CA lic. N/A N/A
C NP CA lic. 10
5 cases
in last 4
yrs.
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 7 of 8
12/2013
EME
11 Intraosseous line placement.
D NP CA lic. N/A N/A
U NP CA lic. 10
2 cases
in the
last 4
yrs or
inservic
e in last
2 yrs.
MED
46 Cardiac stress testing using Persantine. D NP CA lic. N/A N/A
C NP CA lic. 25
25
cases in
last 2
yrs
MED
47 Cardiac stress testing using Dobutamine.
D NP CA lic. N/A N/A
C NP CA lic 10
10
cases in
last 2
yrs.
MED
44 Acupuncture. C NP CA lic
200 hrs.
CME in
acupunctu
re or 10
yrs. exp.
N/A
MED
45 HIV Specialists.
C NP CA lic
Meet
requireme
nts or AB
2168
(attached)
N/A
U NP CA lic.
Meet
requireme
nts or AB
2168
(attached)
see AB
2168 for
qualifica
tions
I certify that I have reviewed the Contra Costa Regional Medical Center Privilege Criteria, and that I meet the specified cri teria for
education/training, experience, and current competence for the privileges, which I have indicated above .
Signatures:
Contra Costa Regional Medical Center
NP Privileges Request Form
Section IV Inpatient Privileges
Practitioner:
NP Section IV Page 8 of 8
12/2013
Requesting Practitioner Date
Division Chair Date Department Chair Date
This is to clarify what is meant by “with consultation”
Outpatient: if the privilege is granted “with consultation,” it means that the NP needs to discuss each patient with a provider who has
unrestricted privileges in the area of consultation. It is at the discretion of t hat provider to determine what the level of detail of this
discussion needs to be.
Inpatient rounding: if the privilege is granted “with consultation,” it means that the NP needs to discuss the patient’s care with an attending
staff physician. It is at the attending staff physician’s discretion to determine what the level of detail of this discussion needs to be.
Procedures: if the privilege is granted “with consultation,” it means that the procedure needs to be discussed with a provider who has th at
particular unrestricted privilege(s) prior to performing the procedure. A procedure log may be kept by the NP to document the procedures
performed.
Contra Costa Regional Medical Center
Midwives Privileges Request Form
Practitioner: _____________________________________
CNM Page 1 of 3
12/2013 Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education & CA licensure Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet
OBSTETRICS & GYNECOLOGY
OBG
1
Outpatient management of low risk prenatal
patient
C CNM, CPM, LM N/A N/A
U CNM, CPM, LM 30 10 cases in
last 4yrs.
OBG
2
Outpatient management of high risk prenatal
patient
C
CNM, CPM, LM
& unsupervised
OBG 1
N/A N/A
U
CNM,, CPM, LM
& unsupervised
OBG 1
30 10 cases in
last 4 yrs.
OBG
4
Antepartum, intrapartum and
postpartum management of pregnancy
with minor complications (such as mild
pre-eclampsia, prior cesarean section) and
uncomplicated vaginal delivery including
amniotomy, episiotomy, second degree
laceration repair and manual removal of
placenta
D
CNM
Recommend NRP
certification
N/A N/A
U
CNM
Recommend NRP
certification
100
8 cases in
last 2 yrs. &
CME in fetal
monitoring
within last 2
yrs.
Name and date of CME course which included Fetal Monitoring:
__________________________________________________________________________________
OBG
5 Antepartum fetal heart rate monitoring
D CNM N/A N/A
U CNM 30 8 cases in
last 4 yrs.
OBG
6
Basic 3rd trimester Obstetrical ultrasound
including viability, placenta location, fetal
number, and amniotic fluid index
D CNM, CPM, LM N/A N/A
U CNM, CPM, LM 10 4 cases in
last 2 yrs.
OBG
9 Induction or augmentation of labor
C CNM N/A N/A
U CNM 10 1 case in
last 2 yrs.
OBG
18 Nexplanon insertion and removal U CNM &
company training N/A N/A
OBG
19 IUD insertion
D CNM, CPM, LM N/A N/A
U CNM, CPM, LM 5 N/A
Contra Costa Regional Medical Center
Midwives Privileges Request Form
Practitioner: _____________________________________
CNM Page 2 of 3
12/2013 Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education & CA licensure Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet OBG
19a Suction Endometrial Biopsy
D CNM N/A N/A
U CNM 5 N/A
OBG
34
Caring for and discharging uncomplicated post
partum patients (for providers without delivery
privileges).
C CNM N/A N/A
U CNM 50 20 in last
2 yrs
OBG
35
Basic first and second trimester ultrasound for
dating, viability, and location of pregnancy.
D CNM, CPM, LM N/A N/A
U
CNM, CPM, LM
4 hours of training
in residency, or
ultrasound course
15 10 in last
2 yrs.
PED
11
Inpatient uncomplicated newborn care (e.g.
normal term newborn and those with indirect
billirubin <15)
C CNM N/A N/A
U CNM 20 3 cases in
last 2 yrs.
OBG
3a
Women’s Health Care Maintenance
Health care maintenance of women including
physical exams and contraception, vaginitis, and
STD’s (for FNPs or CMN, CPM, LMs without adult
medicine privileges).
C CNM, CPM, LM N/A N/A
U CNM, CPM, LM 30 1 yr. in
last 4 yrs.
OBG
3b
General Women’s Health Care
Women’s health problems usually cared for by a
generalist such as, irregular bleeding, evaluation
of pelvic pain, GU, and breast problems (for FNPs
or CMN, CPM, LMs without medicine privileges).
C CNM, CPM, LM N/A N/A
U CNM, CPM, LM 30 1 yr. in
last 4 yrs.
OBG
41 Assist at C-Sections U CMN N/A N/A
OBG
22
Diagnostic D&C incomplete or missed
abortion
D CNM N/A N/A
C CNM 10 N/A
U CNM 20 1 case in
last 4 yrs.
OBG
23 Abortion first trimester
D CNM N/A N/A
C CNM 10 N/A
U CNM & unrestricted
privileges for D&C 20 8 cases in
last 2 yrs.
Contra Costa Regional Medical Center
Midwives Privileges Request Form
Practitioner: _____________________________________
CNM Page 3 of 3
12/2013
I certify that I have reviewed the Contra Costa Regional Medical Center Privilege Criteria, and that I meet the specified cri teria
for education/training, experience, and current competence for the privileges, which I have indicated above.
_____________________________________________________ _____________________________________________________
Signature of Requesting Practitioner Date Signature of Department Chairperson Date
This is to clarify what is meant by “with consultation”
Outpatient: if the privilege is granted “with consultation,” it means that the Midwife needs to discuss each patient with a provider who has unrestricted
privileges in the area of consultation. It is at the discretion of that provider to determine what the level of detail of this discussion needs to be.
Inpatient rounding: if the privilege is granted “with consultation,” it means that the Midwife needs to discuss the patient’s care with an attending staff
physician. It is at the attending staff physician’s discretion to determine what the level of detail of this discussion needs to be.
Procedures: if the privilege is granted “with consultation,” it means that the procedure needs to be discussed with a provider who has that particular
unrestricted privilege(s) prior to performing the procedure. A procedure log may be kept by the Midwife to document the procedures performed.
Contra Costa Regional Medical Center
NP Privileges Request Form
SECTION II OBSTETRICS: High Risk Prenatal Care & Deliveries
NP: _
NP Section II Page 1 of 1
12/2013 Department(s) Number
Privilege Description
D=With Direct Supervision
C=With Consultation
U=Unrestricted D/C/U Training/ Education CA. Licensure Experience Current Competence Requested Granted D=Denied P=Pending CNM=Criteria Not Meet
OBSTETRICS
OBG
2
Outpatient management of high risk prenatal patient
C
NP & unrestricted
privileges in outpt.
mgmt. of low risk
prenatal patient
N/A N/A
U NP Ca. lic. 30
10 cases
in last
4 yrs.
OBG
5
Antepartum fetal heart rate monitoring
D NP Ca. lic. N/A N/A
C NP Ca. lic. 30
8 cases
in last
4 yrs.
OBG
6
Basic 3rd trimester obstetrical ultrasound,
including viability, placenta location, fetal number,
and amniotic fluid index
D NP Ca. lic. N/A N/A
C NP Ca. lic. 10
8 cases
in last
2 yrs.
OBG
22
Diagnostic D&C, incomplete or missed abortion
D NP Ca. lic. N/A N/A
C NP Ca. lic. 10 N/A
U NP Ca. lic. 20 1 case in
last 4 yrs.
23
Abortion first trimester
D NP Ca. lic. N/A N/A
C NP Ca. lic. 10 N/A
U NP Ca. lic.&
Unrestricted
privileges for D&C
10
8 cases
in last
2 yrs
OBG
34
Caring for, and discharging uncomplicated post-partum
patients (for providers without delivery privileges).
C NP Ca. lic. N/A N/A
U NP Ca. lic. 50 20 in last
2 yrs.
Contra Costa Regional Medical Center
NP Privileges Request Form
SECTION II OBSTETRICS: High Risk Prenatal Care & Deliveries
NP: _
NP Section II Page 2 of 1
12/2013
I certify that I have reviewed the Contra Costa Regional Medical Center Privilege Criteria, and that I meet the specified cri teria for
education/training, experience, and current com petence for the privileges, which I have indicated above .
Signatures:
Requesting Practitioner Date
Division Chair Date Department Chair Date
This is to clarify what is meant by “with consultation”
Outpatient: if the privilege is granted “with consultation,” it means that the NP needs to discuss each patient with a provider who has u nrestricted
privileges in the area of consultation. It is at the discretion of that provider to determine what the level of detail of this discussion needs to be.
Inpatient rounding: if the privilege is granted “with consultation,” it means that the NP needs to discuss the patient’s care with an attending s taff
physician. It is at the attending staff physician’s discretion to determine what the level of detail of this discussion needs to be.
Procedures: if the privilege is granted “with consultation,” it means that the procedure needs to be discussed with a provider who has th at
particular unrestricted privilege(s) prior to p erforming the procedure. A procedure log may be kept by the NP to document the procedures
performed.