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Home My WebLink AboutMINUTES - 02102015 - C.20RECOMMENDATION(S): Approve medical staff appointments and reappointments, privileges, advancements to permanent staff and voluntary resignations, as recommended by the Medical Executive Committee at their January 26, 2015 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. APPROVE OTHER RECOMMENDATION OF CNTY ADMINISTRATOR RECOMMENDATION OF BOARD COMMITTEE Action of Board On: 02/10/2015 APPROVED AS RECOMMENDED OTHER Clerks Notes: VOTE OF SUPERVISORS AYE:John Gioia, District I Supervisor Mary N. Piepho, District III Supervisor Karen Mitchoff, District IV Supervisor Federal D. Glover, District V Supervisor ABSENT:Candace Andersen, District II 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: February 10, 2015 David Twa, County Administrator and Clerk of the Board of Supervisors By: June McHuen, Deputy cc: T Scott, C Rucker C. 20 To:Board of Supervisors From:William Walker, M.D., Health Services Director Date:February 10, 2015 Contra Costa County Subject:Medical Staff Appointments and Reappointments – January 2015 CHILDREN'S IMPACT STATEMENT: Not applicable. ATTACHMENTS Attachment Hospitalist priviledges MEC Recommendations – January 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy A. New Medical Staff Members Abdelaziz, Hala, MD Pathology Boutros, Shadi, DDS Dental Garrett, Wayne, DO Pathology Helfend, Lisa, MD Pathology Hubbell, Jared, MD Emergency Medicine Melny, Richard, MD Psychiatry/Psychology Murguia, Brandon, MD Internal Medicine Pap, Diane, MD Diagnostic Imaging Parvin, Nilofar, DDS Dental Tang, Edward, MD Surgery Walters, Walter, MD Anesthesia B. New Staff Affiliation McDonald, Diana, FNP Family Medicine C. Request for Additional Privileges Jon Beauchamp, MD Emergency Medicine Alison Block, MD Family Medicine Priyanka Tulshian, MD Internal Medicine D. Advancement to Permanent Staff Dan Barrett, DO Psychiatry/Psychology Harleen Sethi, DMD Dental E. Biennial Reapointments Gloria Asuncion, MD Pathology C Brea Bondi-Boyd, MD Family Medicine P/A Grace Cavallaro, MD Obstetrics & Gynecology A Alex Espinoza, MD Pediatrics C Susan Feierabend, MD Obstetrics & Gynecology A Imtiaz Ghori, MD Pediatrics A Alexander Gorodetsky, MD Psychiatry/Psychology C Karine Hajyan, DO Obstetrics & Gynecology A Estela Hernandez, MD Emergency Medicine A Malcolm Johnson, MD Emergency Medicine P/A Paul Kwok, DO Anesthesia A Stuart Lovett, MD Obstetrics & Gynecology C Julie Nguyen, MD Emergency Medicine P/C William Peterson, MD Emergency Medicine A Michael Price, MD Diagnostic Imaging C Charles Saldanha, MD Psychiatry/Psychology A Vinod Sharma, MD Psychiatry/Psychology A Lisa Wang, MD Psychiatry/Psychology A MEC Recommendations – January 2015 Definitions: A=Active C=Courtesy Aff=Affliate P/A= Provisional Active P/C= Provisional Courtesy Matthew White, MD Psychiatry/Psychology C Mark Wille, MD Internal Medicine A Peter Won, MD Diagnostic Imaging A F. Biennial Renewal of Privileges Phyllis Howard, NP Family Medicine Aff G. Teleradiology Renewal of Privileges Jonathan Bold, MD Diagnostic Imaging C Carla Lloyd, MD Diagnostic Imaging C Michael Novick, MD Diagnostic Imaging C Tara Otto, MD Diagnostic Imaging C Susan Park, MD Diagnostic Imaging C John Rule, MD Diagnostic Imaging C H. Vountary Resignations Jason Appel, MD Surgery Sara Banerjee, MD Diagnostic Imaging (Teleradiologist) Pil Choo, MD Pathology Tara Collins, MD Psychiatry/Psychology Jennifer Liu, DDS Dental Faisal Mirza, MD Surgery Linda Nakell, Phd Psychiatry/Psychology Gary Yee, DDS Dental I. Proposal for new Hospitalist privileges New privileges form for Hospitalists (final draft) was reviewed and approved as written. (Attachment 1) Contra Costa Regional Medical Center Privileges Request Form D CA Lic.N/A N/A C 10 1 case in last 2 years U 15 5 cases in last 2 years D CA Lic.N/A N/A C 5 1 case in last 2 years U 10 5 cases in last 2 years D CA Lic.N/A N/A C 5 1 case in last 2 years U 10 5 cases in last 2 years D CA Lic or DDS or DMD N/A N/A U CA Lic.10 2 cases in last 4 years ANE CC DEN DIA EME FAM GER HOSP IM OBG PED SGN ANE CC DIA EME HOSP IM SGN Departments (s)ANE CC DIA EME HOSP IM SGN ANE CC EME HOSP IM SGN ANE 11 Endotracheal Intubation* Hospitalist Current CompetenceUse of Propofol for moderate (conscious sedation)*Unrestricted ANE 3 and written exam ANE 3 Moderate (conscious) Sedation* Does NOT include use of ketamine or propofol. CA Lic. And Airway Management skills (ANE11 or inservice) ANE 3A Use of Ketamine for moderate (conscious sedation)*Unrestricted ANE 3 and written exam ANE 3B Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience Requested* Separate proctoring required HOSP Updated JAN 2015 Page 1 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 10 5 cases in last 4 years U AN, EM, FP, IM, or Surg 20 5 cases in last 2 years D AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 10 5 cases in last 4 years U AN, EM, FP, IM, or Surg 20 5 cases in last 2 years D AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 10 5 cases in last 4 years U AN, EM, FP, IM, or Surg 20 5 cases in last 2 years D AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 5 5 cases in last 4 years U AN, EM, FP, IM, or Surg 10 5 cases in last 2 years D CA Lic.N/A N/A U CA Lic.4 1 case or inservice in last 4 years ANE CC HOSP IM CC HOSP Adult arterial line placement, monitoring and management CC HOSP IM CC 2 ANE CC EME HOSP IM Ventilator Management of Critically Ill Patients* Peritoneal Lavage*EME HOSP EME 1 CC 5 CC 10 Limited bronchoscopy on Patients for Mucus Plug Washing or Localization of Bleeding* Adult Central Venous Line Placement, Monitoring and Management* CC 6 * Separate proctoring required HOSP Updated JAN 2015 Page 2 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic.5 N/A C CA Lic.N/A N/A U CA Lic.N/A 1 year in last 4 years C CA Lic.N/A N/A U CA Lic.N/A 1 year in last 4 years C CA Lic.N/A N/A U CA Lic.N/A 1 year in last 4 years C CA Lic.N/A N/A U CA Lic.N/A 1 year in last 4 years EME HOSP EME 10 U CA Lic.10 N/A D CA Lic.N/A N/A U CA Lic.N/A 2 cases in last 4 years or inservice in last 2 years Provision of general emergency care, including assessment, treatment and interpretation of lab and study results (e.g. x-rays EKGs, etc.), and basic microscopy 14 years old - 65 years old EME 11 EME HOSP EME 4 EME HOSP EME 8 Bedside Testing in the ED (POCT) Stool Guiac. Gastrocult. EME 7 EME HOSP EME 5 CC EME HOSP IM PED Intraosseous Line Placement EME HOSP Provision of general emergency care, including assessment, treatment and interpretation of lab and study results (e.g. x-rays EKGs, etc.), and basic microscopy 0 - 36 months Incision & Drainage or needle aspiration of peritonsilar abscesses Provision of general emergency care, including assessment, treatment and interpretation of lab and study results (e.g. x-rays EKGs, etc.), and basic microscopy > 50 years old EME 6 Provision of general emergency care, including assessment, treatment and interpretation of lab and study results (e.g. x-rays EKGs, etc.), and basic microscopy 36 months - 21 years old EME HOSP * Separate proctoring required HOSP Updated JAN 2015 Page 3 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic.5 1 case in last 4 years D CA Lic.N/A N/A C CA Lic.10 2 cases in last 4 years U CA Lic.20 6 cases in last 4 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years Confirm intrauterine pregnancy (IUP), and detection of fetal heart tones and dating of pregnancy EME HOSP EME 16C Evaluation of abdominal aortic aneurysm (AAA) EME HOSP EME 16B EME 16A EME HOSP EME HOSP EME 12 Documentation and/or localization of fluid in the abdomen, chest, subcutaneous tissue and joints EME HOSP EME 13 Orthopedics: Closed reduction of mild to moderately displaced fractures of hand, forearm, ankle, etc. & Reduction of various dislocated joints Joint Aspiration and Joint Injection * Separate proctoring required HOSP Updated JAN 2015 Page 4 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years EME 16E EME HOSP EME 16D Evaluation of gallbladder for gallstones, common bile duct dilatation, gallbladder wall thickening, and sonographic Murphy's sign Evaluation of renal track for hydronephrosis and bladder distension EME HOSP EME HOSP EME 16F Basic cardiac ultrasound to assess for pericardial effusion, global left ventricular contractility, right ventricle size, IVC diameter, and confirmation of pulseless electrical activity, and asystole EME HOSP EME 16G EME EME 16H Evaluation of lower extremities for deep venous thrombosis Localization of veins for central and peripheral venous access * Separate proctoring required HOSP Updated JAN 2015 Page 5 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic. & approved Sono Course or Residency Training 15 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic.30 10 cases in last 2 years EME EME 16I EME EME EME 16K EME FAM HOSP Evaluation for pneumothorax 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. Localization of nerves for peripheral nerve block EME 16L Detection of foreign body FAM 1 EME EME 16J Evaluation of eye for detached retina and vitreous detachment * Separate proctoring required HOSP Updated JAN 2015 Page 6 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic.20 N/A D CA Lic.N/A N/A U CA Lic.10 N/A FAM HOSP FAM 11 U CA Lic.10 N/A C CA Lic.N/A N/A U FP or IM N/A 6 mos. in last 4 years C CA Lic.N/A N/A U FP or IM N/A 6 mos. In last 4 years CC FAM GER HOSP IM MED 4 CC FAM HOSP IM MED 3 DERM FAM HOSP FAM 2 General Inpatient Care: Including healthcare maintenance, initial interpretation of lab and study results (e.g. x-rays, EKGs, etc.), excluding all cases where expected improvement is not soon apparent or specialized therapeutic or diagnostic techniques are needed 14 years - 65 years old General Inpatient Care: Including healthcare maintenance, initial interpretation of lab and study results (e.g. x-rays, EKGs, etc.), excluding all cases where expected improvement is not soon apparent or specialized therapeutic or diagnostic techniques are needed > 50 Years Corneal Abrasions, Corneal Foreign Body Removal Bedside Testing in Family Medicine (POCT): KOH and Saline Prep, Vaginal pH, Fern Test, Amniotest and Urine Dipstick FAM HOSP FAM 3 Skin Biopsy, Dermal Excision, Dermal Hyfercation and Dermal Cryotherapy (EME) * Separate proctoring required HOSP Updated JAN 2015 Page 7 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedC CA Lic.N/A N/A U FP or IM 1 year 1 year in last 2 years C CA Lic.N/A N/A U IM 1 year 1 year in last 2 years D CA Lic.N/A N/A U CA Lic.5 N/A D CA Lic.N/A N/A U CA Lic.5 1 case in last 4 years CC HOSP IM MED 10 MED 7 Lumbar Puncture FAM HOSP IM CC EME FAM HOSP IM SGN CC GER HOSP IM MED 8 Complex Inpatient Medical Care as above... >50 years old Bone Marrow Aspiration MED 9 Complex Inpatient Medical Care: Physicians 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 physicians 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 level of competence; C. Specialization treatment or procedures are contemplated with which they are not familiar. 14 years - 65 years old * Separate proctoring required HOSP Updated JAN 2015 Page 8 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 3 1 case in last 4 years U AN, EM, FP, IM, or Surg 3 1 case in last 2 years D CA Lic.N/A N/A U CA Lic.3 N/A D CA Lic.N/A N/A U CA Lic.15 5 cases in last 4 years D AN, FP, IM or Surg N/A N/A C AN, FP, IM or Surg 30 5 cases in last 4 years U AN, FP, IM or Surg 80 5 cases in last 2 years D AN, EM, FP or IM N/A N/A C AN, EM, FP or IM 3 1 case in last 4 years U AN, EM, FP or IM 5 1 case in last 4 years CC HOSP IM MED 11 Pericardiocentesis* FAM HOSP IM OBG SGN MED 12 Rigid Sigmoidoscopy Flexible Fiberoptic Bronchoscopy* CC HOSP IM MED 23 Elective Cardioversion FAM HOSP IM SGN MED 18 Flexible Sigmoidoscopy MED 21 CC HOSP IM STH * Separate proctoring required HOSP Updated JAN 2015 Page 9 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD AN, EM, FP, IM, or Surg N/A N/A C AN, EM, FP, IM, or Surg 3 N/A U AN, EM, FP, IM, or Surg 5 1 case in last 2 years C FP or IM 2 cases or Gambro intro classes, or CRRT conf. in last 2 years 1 case in last 2 years U Nephrology N/A 2 cases in last 4 years D FP or IM N/A N/A U FP or IM "U" MED 26 & 20 exercise treadmills 1 year experience in last 4 years D FP or IM N/A N/A U FP or IM 50 20 cases in last 4 years C FP or IM N/A N/A U FP or IM 30 10 casses in last 2 years CC HOSP IM SGN MED 24 Tracheostomy Management* CC HOSP IM MED 25 Continuous Renal Replacement Therapy HOSP IM MED 28 Exercise Stress Test Pulmonary Function Interpretation HOSP IM MED 31 Cancer Chemotherapy HOSP IM MED 30 * Separate proctoring required HOSP Updated JAN 2015 Page 10 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedCompleted Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Medical Subspecialty: Cardiology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U HOSP IM MED 33 Medical Subspecialty: Endocrinology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U U HOSP IM MED 35 Medical Subspecialty: Hematology/Oncology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U HOSP IM Medical Subspecialty: Gastroenterology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. MED 34 CC HOSP IM MED 32 * Separate proctoring required HOSP Updated JAN 2015 Page 11 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedCompleted Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years HOSP IM MED 36 Medical Subspecialty: Infectious Disease Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U U CC HOSP IM MED 38 Medical Subspecialty: Pulmonary Medicine Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U HOSP IM MED 39 Medical Subspecialty: Rheumatology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U HOSP IM MED 37 Medical Subspecialty: Nephrology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. * Separate proctoring required HOSP Updated JAN 2015 Page 12 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedCompleted Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years Completed Subspecialty training and BC/BE in that subspecialty N/A 1 year experience in last 4 years FP or IM 5 years 1 year experience in last 4 years U HOSP IM MED 41 Medical Subspecialty: Allergy/Immunology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U MED 40 CC HOSP IM Medical Subspecialty: Critical Care Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. U UMED 43 Medical Subspecialty: Dermatology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. HOSP IM Medical Subspecialty: Neurology Physicians with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultant and should, in turn, request consultation from within or outside the hospital staff whenever needed. DERM HOSP IM MED 42 * Separate proctoring required HOSP Updated JAN 2015 Page 13 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD FP or IM N/A N/A U FP or IM 20 & MED 28 5 cases in last 2 years D FP or IM N/A N/A U FP or IM 20 & MED 28 10 cases in last 2 years D CA Lic.N/A N/A U CA Lic.10 4 cases in last 2 years FAM HOSP OBG OBG 18 U CA Lic. and Company Training N/A N/A D CA Lic.N/A N/A U CA Lic.5 N/A D MD N/A N/A U MD 5 N/A D FP, OB, or EM N/A N/A U FP, OB, or EM 3 N/A OBG 20 FAM HOSP OBG FAM HOSP OBG OBG 19 Cardiac Stress Testing Using Persantine Cardiac Stress Testing Using Dobutamine OBG 6 EME HOSP OBG Culdocentesis Nexplanon Insertion and Removal MED 47 Basic 3rd Trimester Obstetrical Ultrasound Including: Viability, Placenta Location, Fetal Number, and Amniotic Fluid Index* IUD Insertion FAM HOSP OBG OBG 19A HOSP IM MED 46 HOSP IM Suction Endometrial Biopsy * Separate proctoring required HOSP Updated JAN 2015 Page 14 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedC CA Lic.N/A N/A FP or OB N/A 20 cases in last 2 years CA Lic.50 20 cases in last 2 years FAM HOSP OBG OBG 35 U CA Lic. And 4 hours training in residency or ultrasound course 15 10 cases in last 2 years C CA Lic.N/A N/A U CA Lic.20 3 cases in last 2 years C CA Lic.N/A N/A U CA Lic.20 3 cases in last 2 years D FP or Peds N/A N/A U FP, Peds or ENT 5 5 cases in last 2 years FAM HOSP OBG SGN SGN 1 U CA Lic.20 N/A U EME ENT HOSP FAM SEN 6 Complex Non-operative Diagnosis & Management of ENT Problems: Including complex removal of FB nose and ear, anterior post nasal packing, indirect laryngoscopy FAM HOSP PED PED 12 Surgical Assisting Basic 1st and 2nd Trimester Ultrasound for Dating, Viability, and Location of Pregnancy FAM HOSP OBG OBG 34 Caring for and Discharging Uncomplicated Post Partum Patients (For Providers w/o Delivery Privileges) FAM HOSP PED PED 11 Inpatient uncomplicated newborn care (e.g. normal term newborn and those with indirect bilirubin <15mg%); including Frenotomy Care of newborns with complicated but non-life-threatening problems (e.g. low birth weight, but > 2000gms.; total bilirubin <18mg%, transient hypoglycemia not requiring IV therapy; suspected sepsis or temperature instability, congenital anomalies without distress, anemia, uncomplicated TTN.) * Separate proctoring required HOSP Updated JAN 2015 Page 15 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD CA Lic.N/A N/A U CA Lic.5 1 case in last 4 years D CA Lic.N/A N/A U CA Lic.5 1 case in last 4 years D CA Lic.N/A N/A U CA Lic.5 2 cases in last 4 years D CA Lic.N/A N/A U CA Lic.5 2 cases in last 4 years D CA Lic.N/A N/A U AN, EM, FP, IM, or Surg 5 1 case or inservice in last 2 years D CA Lic.N/A N/A U CA Lic.5 1 case or inservice in last 2 years SGN 10 Needle Thoracostomy and Thoracic Vent CC EME HOSP IM SGN SGN 9 Chest Tube Insertion* EME HOSP PED SGN HOSP SGN SGN 8 Biopsy: Breast, Thyroid, Lymphnode, subcutaneous Nodule* CC EME FAM HOSP IM SGN SGN 5 Paracentesis FAM HOSP IM OBG PATH SGN SGN 7 FNA - Fine Needle Aspiration CC EME FAM HOSP IM SGN SGN 4 Thoracentesis * Separate proctoring required HOSP Updated JAN 2015 Page 16 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedHOSP IM SGN SGN 11 U State License for Fluoroscopy N/A N/A D CA Lic.N/A N/A U CA Lic.20 N/A D FP N/A N/A C FP 10 6 cases in last 2 years U FP or Surg 15 6 cases in last 2 years D CA Lic.N/A N/A U CA Lic.5 1 case or inservice in last 4 years D CA Lic.N/A N/A C CA Lic.5 2 cases in last 2 years U CA Lic.10 5 cases in last 4 years D FP, IM or Surg N/A N/A C FP, IM or Surg 10 N/A U FP, IM or Surg 20 N/A EME HOSP SGN SGN 17 Suprapubic Catheter Placement Basic diagnosis and management of surgical problems: Anoscopy, needle drain cysts, I&D abscesses, wound debridement, excision of moles and sebacious cysts, initial management acute abdomen SGN 12 Basic General Surgery Operative Procedures:* I&D of prianal abscess, RX of anal fissures and hemorrhoids; appendectomy, herniorraphy, rigid sigmoidoscopy EME FAM HOSP SGN Fluoroscopy During Surgery HOSP SGN SGN 13 HOSP SGN SGN 19 Non-operative Diagnosis and Management of Complex Breast Disease EME HOSP SGN SGN 18 Repair of Complex Lacerations and Extensor Tendon Repair * Separate proctoring required HOSP Updated JAN 2015 Page 17 of 18 Contra Costa Regional Medical Center Privileges Request Form Departments (s)Hospitalist Current Competence Practitioner Name: _______________________ GrantedD= Denied P= Pending CNM=Criteria Not Met Training/ Education D= With Direct Supervision C= With Consultation U= Unrestricted NumberPrivilege Descriptions D/C/U Experience RequestedD FP N/A N/A C FP 10 6 cases in last 2 years U FP or Surg 15 6 cases in last 2 years D CA Lic.N/A N/A U CA Lic.5 biopsies 2 cases in last 4 years D CA Lic.N/A N/A C CA Lic.5 2 cases in last 4 years U CA Lic.10 6 cases in last 4 years FAM HOSP IM OBG PATH SGN HOSP SGN SGN 20 I&D of Complex Breast Abscesses, Open Biopsy, Needle Loc Biopsy* Date ____________________________________________________ ____________________________________________________ Signature of Division Chairperson I certify that I have reviewed the Contra Costa Regional Medical Center Privilege Criteria, and that I meet the specified criteria for education/training, experience, and current competence for the privileges that I have indicated above. EME FAM SGN ORTH SOR 1 Orthopedics: Splints and Circumferential Casting, Reduction of Uncomplicated Dislocations SGN 26 Core Needle Biopsy Date ____________________________________________________ Signature of Department Chairperson Date Signature of Requesting Practitioner * Separate proctoring required HOSP Updated JAN 2015 Page 18 of 18