Bradley Rodgers Department ofSurgery...~\~CV\.bt..-6 . D\... e - .3.' zl. zs{'\'\ ftoe~ ~~ DATE CLINIOIAN . SIG ~ URE. . . As . the Division HeadlQI Liaison and Department ChairlMedical

$Page 1: Bradley Rodgers Department ofSurgery...~\~CV\.bt..-6 . D\... e - .3.' zl. zs{'\'\ ftoe~ ~~ DATE CLINIOIAN . SIG ~ URE. . . As . the Division HeadlQI Liaison and Department ChairlMedical$














Clinical Privileges Update Form

Bradley Rodgers Department of Surgery

I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency):

New Privileges to be Added (please indicate category level and type of experience):

Current Privileges not to be Renewed: *

;*p;'i;il~ge;'~;;i;:enewed are not reported as being volunt~rily relinquished unless this is done while you are under Investig;ti~n; lor, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you iwill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

As the Division Head/QI Liaison and Department Chair/Medical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: .

O#,t-I.,ve: f"IVIt..~tf rt>-t.,.., j2{;VII::we P . We find as follows:

[:8J Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested

Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in __ months.

Should have clinical privileges granted but restricted as f~:_

7 ij ~~~~.-..... --__ DATE DIVISION HEAD/QI LIAISON SIGNATURE

~-----.luLL---- 1~-------.-----...~-----.--...... DATE DEPARTMENT CHAIR SIGNATURE

Revised 311/2006

pc ;

Clinical Privilc'~2es Update Form


I have reviewed the privileg(~s previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges request~d. (please include supporting documentation to verify competency):

New Privileges to be Added' (please indicate category level and type of experience):

Current Privileges not to IJe Renewed:*

"Privileges not renewed are not reported as being voluntarily relinquished unless this Is done while you are under investigation; or, in return for not conducting an In7estigation or proceeding. Ifprivileges are to be reported as voluntarily relinquished you

. will be notified and receive a copy of l:he report to be filed with the National Practitioner Databank.

DATE

As the Division HeadlQI Liaisc)n and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of expeitience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree tbat the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from tbe following sources of quality and utilization data: .

We find as follows: ~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as

requested

Concerns noted on re\liew with corrective action plan In place with recommendation of reappOintment to the clinical staff witf. privileges as requested, but subject to a review in __ months.

Should have clinical privileges granted but restricted as follows: _____________

(;J ~#--DATE -~--,l-Q-~-=-.IQI LIAISON SIGNATURE--r

DATE DEPARTMENT CHAIR SIGNATURE

Revised 3Il1Z006

requested



I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency):


<"" o

Current Privileges not to be Renewed:* /'o

*Privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for notconducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy of the report to be filed with the National Practitioner Databank.

DATE

As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:

llows:

Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges, as

D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in __ months.

Should have clinical priv'ileges granted but restricted as follows:, ______________D

DEPARTMENT CHA SIGNATURE

DATE

DATE Revised 3/1/2006



I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience):

rV)A

Current Privileges not to be Renewed:*

ts/A

,*privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; or, in return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you Iiwill be notified and receive a copy of the report to be filed with the National Practitioner Databank.

DATE

As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:

ID Number: 686618

Inpatient Attending Performance

Drug Usage Reports

Outpatient Clinical Practice

Infection Reports

Morbidity/Mortality Reports

PatienUFamily Satisfaction

Physician's Health & Mental Status

Sentinel Events/Risk Management Reports

Medical Records Reports

UnschedUled Readmissions L-

we~mdsfollows: . Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested

D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in __ months.

______________________________________________________________~~~~--~~r) y~4~

D

DATE

DATE

Should have clinical privileges granted but restricted as follows:___::------,f________

Revised] 011710]

--------------------------------

'. Clinical Privileges Update Form


I have reviewed the privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience):

Current Privileges not to be Renewed:*

--..~

!*Privileges not renewed"';";:;; not reported as being voluntarily relinquished unless this is done while you are under investigation; lor, in return for not conducting an investigation or proeeeding. If privileges are to be reported as voluntarily relinquished you l'I'I'i11 be notified and receive a copy of the report to be filed 'l'l'ith the National Praetitioner Databank.

DATE

As the Division Head/QI Liaison and Department ChairlMedical Director, have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data:

10 Number: 686618


Drug Usage Reports


Infection Reports


Patient/Family Satisfaction




Unscheduled Readmissions

We find as follows:

[K] Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested

Concerns noted on review with corrective action plan in place with recommendation of reapPOintment to the clinical staff with privileges as requested, but subject to a review in __ months.

Should have clinical privileges granted but restricted as follows:___r-_+________

DATE

•

DATE DEPARTMENT CHA:IR SIGNATURE Revi,edIOlJ7IDI\ \

---_.-------------

.

c with recommendation of reappointment :!.J'l'lR ,t;\JJ:)je1~IO a review in _ months.

CO-CHAIR SIGNATURE



I have reviewed the privileges p'reviously granted to me and request the following changes:

New Privileges to be Added (please indicate category level and type ofexperience):

Cp.rrent Privileges not to be Renewed:·

Fprl-;n-;g;-;~t ren~-;'re not reported as being voJuntariIY'~quisbed unl_ this is d~;~ "Me YOIl are ~~;~-;-;.::\in return for not conducting an investigation or proceeding. ItprlvUeges are to be reported as voluntarily reUnquished you will be !notlfied and receive a copy of the report to be med with the National Practftioner Databank. ~

DATE

As the Division HeadlQI Liaison and Department ChairlMedical Director, we have reviewed the abovename~ clinician's level of experience, past performance and quality indicators (if renewing privileges) as

, related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewe~ applicable info,nnation from the fOUOlling , sources of quality and utilization data:

10 Number: 686618


Drug Usage Reports


Infection Reports


PatienVFamily Satisfaction

Physician'S Health & Mental Status




We find as follows:

~Acceptable review with recommendation' of reappointment to the clinical staff with clinical privileges as requested

o Concerns noted on review with corrective to the clinical staff with privileges as req

~n DATE

DATE . I ~J</0)

DATE. I ]

onths

~1 ~ :

.,' (~,.'



I have reviewed the privileges previously granted to me and request the following changes:


Current Privileges to be Changed:

~ \~CV\. bt..-6 D\...

e - .3.'

zl zs{'\'\ ftoe~ ~~ DATE CLINIOIAN SIG ~ URE. . .

As the Division HeadlQI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above name!l clinician's qualifications are appropriate. Since the dat~ of the last appointment, we have reviewed applicable information from the following . sources of quality and utilization data: .

/ Inpatient Attending Performance


Drug Usage Reports


Infection Reports




PatienUFamily Satisfaction


We find as follows:

o Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested

o Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subjectto a review in .

DATE

DATE

-S;C ~.

" . ~

'. :' >

ADDENDUM TO APPROVED PRIVlLEGES

Ipediatric Surgery

:IBradley ~~~~~========J~IM_.D_·__~I

Please check those types of lasers that you are requesting privileges for, and indicate type of training/experience.

';fYPE OF EXPERIENCE: 1 Completed fonnal training

2 Limited expedence - without' fonnal training

3 Extensive Experience - without fonnal training

PRIVILEGES

LASER SURGERY REQUEST PRIVILEGES TYPE OF EXPERIENCE:

CO 2 V WAc-iS· CD YAG V ,4y;.~~ I wfhU:S (D ARGON

HOLMIUM

PULSED DYE

KTP

PULSED CO 2

.DATE .

As Divisiori Head/QI Liaisori and Department Chair, we have reviewed the above-named c.linician's level of experience and past performance as related to requested privileges and agree that e clinician's qualifications are appropriate.

"7:z

return camp eted form to Credentials Office, Box 1000I HSC

" .. , ., REQUEST FOR CLINICAL PRIVILEGES

Department of Surgery University of Virginia Health Sciences Center

Bradley M~reland Rodgers Name

Johns Hopkins Medical School'l966 Medical School and Year of Graduation

, , ,

Duke IInjyersjty Medical Center J966-1973 Residericy Training Location and Years·" .

Montreal Children's Hospital, Montreal, Canada, 1973-74 Fellowship/Post-Residency Training Location and Years

Americar of SUrgery. 'American Board of 'I'horacic S"rgery, Board Certification in ABS: Special, Competence in Pediatric Surgery, Criticc

1974.1975,1976.1995,1989 Care Year of Certification

Admitting Privileges? 4l Yes 0 No' Virginia Ambulatory Surgerypenter PriVileges? £] Yes 0 No

PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK.

, " """ ',',' .'" .' . .... ' . . I ME.DJCIJI!. ' . .• ~ '.'. •.......:.t #.. ..". H ...". ..

Accordin() to c8te()ory, enter A, B or C in the REQl/ESTED column.

Category A ' The applicant will not 'undertake patient management except in emergency.

Category B The applicant will occasionally manage patients or assist in management. Consultation will be sought in the event of anticipated or actual difficulties.

Category C The applicant will independently manage patients. The applicant would be expected to request consultation only occasionally.

Accordin() to type, enter 1, 2, or 3 in the EXPERIENCE column.

Type 1 Completed Formal Training Program

Type 2 limited E~perience - without formal training

Type 3 , Extensive Experience - without formal training ~-------------=------~~~====~============~I

, ,.,< .' ',,:' ',.. ,.:, ,•• ':, , ... " " CATEGORY TYPE ' . . ' , .. PRIVilEGES REQUESTED . , . < AREAS ' . . REQUESTED EXPERIENCE

,':.:.",::: ::','.:,,:.:"::, "'" ,::,:, ..": . . , , " :': .. 'IA.BorCI tf,,2or3J

GENERAL SURGERY Disease Diagnosis and Treatment a. 1----.._--- Interpretation of tests , ~ I

THORACIC AND CARDIOVASCULAR Disease SURGERY Diagnosis and treatment

Interpretation of tests

PEDIA TAlC SURGERY Disease Diagnosis and treatment _L__._~--

C ,Interpretation of tests

•

DiseaseTRANSPLANT SURGERY c--Diagnosis and treatment c.-.---Interpretation of tests

-

Category A

Category B

Category C

Type 1

Type 2

Type 3

According to category, enter A, B or C in the REQUESTED column.

The applicant will not undertake the procedure except in emergency. .'

The applicant will occasionally perform or assist in the performance of the procedure. Consultation will be sC!ught in the event of anticipated or actual difficulties.

The applicant will perform the procedure. The applicant would be expected to request consultation only occasionally. .

According to type, enter 1, 2, or3 in the EXPERIENCE column.

Completed Formal Training Program

Limited Experience - without formal training

Extensive Experience - without formal training

GENERAL SURGERY

Biopsy Breast

Lymph node

Major organs

Muscle

Other (specify)

Br'onchdplasty

Excision Lesions

Neoplasm

Tumors

Other (specify)

Incision and drainage

Abscess

Hematoma

Other (specify)

---------

----- --

--

-----------------

-----

. ,. ~:!fG .t II. PROCEDURES (cont'd) . , . Page 3· i - . CATEGORY TYPE I

PRIVILEGES REQUESTED AREAS REQUESTED EXPERIENCE fA, Bore} (1~ 2 or3J _C!.-__Insertion of central venous line Iio-._---

I ' Insertion of chest tube

c:..-_r--.---- -~--Insertion of Swan-Ganz catheter . t,--L 'Kidneys and Adrenal glands - -----~~--Laparoscopy

~.-----~--.L..__Laryngoplasty M.__ \ '---_.k __ \ Liver and biliary tract

Laryngoscopy _L__ --r--t----1--

Mastectomy -""1--" Pancreas =L==~.--.--,

IParotid proc!dures 1--'----.1:...:::..__Parathyroid procedures _.. \ ~.-----"

Removal of _._----r-e.-, rForeign, body _._--. Implant r_._--:= ~== Other (specify) -_.__. -_._-

Repair traumatic wounds I __f2-== ---r--__Rel?air cong~nital deform!!;y .... _._---_. ~'--' I ' Retroperito~.e~1 exploratio!!__ _._---7""'~--Sigmoidoscopy -'-"'-,-

, Flexible' _L.:..__ \ l ' Rigid ' ' ..._-. -~--___k __ i_~.'5!.~_~r.~!ts.. ....__._.... _ ••10. -_.--_.1:--::. __ { .._.Spleen ....._.........._----- __c.....___--,r--

_!~yroid p'!£~dures ----_._--- 1--------,..T rache.£e!asty .__L __-_._--_.. --r--{' .Tracheostomy

_C:-____PEDIATRIC SURGERY Diaphragm I--.....i--- . _ ...J____..__t.:___Endoscopic procedures _......__. Esophagus and diaphragm t_C::._..:.-_ -'---' All procedures involving resection, repair,

reconstruction: diyerticulectomy, .-'!!!Q.e.t!!P'!ctomYd~~.~E.h..!~.29.astro~~y'.!."!!S._ --_._.. ----_.

' , . ~1;_____Gastrointestinal tract ,"_-_0.. :'-_..._._-_...--._._'- .....--~...--.~ Lungs

I •• __• • ••--_._-- ---_...~---_T.rach~bronchial procedures IC -_.._--._---

Vessels -------r--.--- _J.___Repair, reconstr~ction with bypass grafts -~---_t.--__Endarterectomy I1--._--Other (specify)

• ~ If II. PROCEDURES (cont"d) ~> :a. " Page 4:''S .~~

CATEGORY 'TYPE-PRIVILEGES REQUESTED' AREAS REQUESTED EXPERIENCE

/ lA, BorCI (1,,2OT3J THORACIC AND Arrythmia ablation fJr _ CARDIOVASCUlAR 1--'---'

Cardiopulmonary bypass

k= r--1._--Chest Wall I--..l----

All procedures involving chest wall or pleura: Eleurectomy, decortication, thoracoElasty, etc. ----

Closed heart .;...- A_____

r------:-Myocardial revascularizatjon '(with/without grafts) ---------Other (specify) - ---_.

Implantation of mechanical devices -7\===-----Lung __i:.:___ ~---.---All procedures involving resection, repair,

reconstruction or biopsy: pneumonectomy, lobectomy, segmentectomy, etc. --------_.Other (specify) ...,.-'------_._-

=A--==Open heart • -----Reconstruction with graftsftransplantation ------,---Valve replacement ------~.----Valvuloplasty .-------c,.----j-----

Pericardial procedures _. ..... ~.-.------.. --_._-_...--_...,-Trachea and Bronchi

. All procedures involving repair, reconstruction

--_._---------or resection: tracheostomy, bronchotomy, etc. _C::.__=- ,

--.-'-.. Other (specify) - . ..- .. -I--e::---T----

Tumors, cardiac/pericardial . .

TRANSPLANT SURGERY Heart It..__._ ___no rr • ____

=8===---------Uver --.---- ------.. ~---- -i----~----_Multiorgan -_...__.-_.._- .._- .}......------

Pancreas A --_._.._.._....-----_.. .... , _.._---- --(1;--Renal i .

OTHER Conscious sedation .. ._C::.__....__ _ L._____ ... -_._--_._......_- -_. ... -_._-_ . --_.. ._---------

-----.--"71------- .._----_._ -_.--.

DATE ~ I . ~C\ ,OQ\1 ~O~ J~fJ'='

~ CLl~AN

As Divl Head/Ol liaison and Department Chair. we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that clinician's qualifications are apptopriate. We recommend approval of the requested privileges.

DATE __________________________________________

din pri •• urR;n 122195

Documents

Bradley Rodgers Department ofSurgery...~\~CV\.bt..-6 . D\... e - .3.' zl. zs{'\'\ ftoe~ ~~ DATE CLINIOIAN . SIG ~ URE. . . As . the Division HeadlQI Liaison and Department ChairlMedical