DELINEATION OF PRIVILEGES - GENERAL SURGERY … · DELINEATION OF PRIVILEGES - GENERAL SURGERY ... Adults and Pediatrics Unless Specified ... Once the provider has successfully passed

Plastic Surgery 5/2017

KALEIDA HEALTH

Name ____________________________________ Date ____________________

DELINEATION OF PRIVILEGES - GENERAL SURGERY

DIVISION OF PLASTIC SURGERY Adults and Pediatrics Unless Specified

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow

or line to make selections. We will return applications that ignore this directive.

GENERAL STATEMENTS

Privileges in Surgery are separated into the following divisions: General Surgery and Plastic Surgery. Applicants desiring procedure

privileges in more than one division must complete separate forms for each division requested.

Procedures are grouped by anatomic region.

Procedures are also separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education

and experience. In general, procedures learned during residency are grouped in Level I and are granted upon evidence of successful

completion of residency training. Level II procedures may or may not require evidence of additional training beyond residency.

Documentation of additional training and/or experience is required for all Level III procedures.

LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful

completion of an accredited residency program in that core specialty.

The removal or restriction of these privileges would require further

investigation as to the individual’s overall ability to practice, but there is

no need to delineate these privileges individually.

Admission and Follow-Up

History and Physical for diagnosis and treatment

INJECTION PROCEDURES

Injection Steroid

I & D / DEBRIDEMENT

Debridement

Debridement, Dressing Change

Re-Exploration Breast Evacuation Hematoma

Incision and Drainage

BIOPSY AND EXCISIONS

Biopsy (finger, hand, muscle, sural nerve)

Excision Basal Cell Carcinoma

Excision Breast Mass, Bilateral

Excision Cyst Sebaceous

Excision Hemangioma Upper Extremity

Excision Hidradenitis, Axillary/Buttocks

Excision Lesion and Reconstruction

Excision Lesion Eyelid, Benign/Malignant

Excision Lesion Hand

Excision Lesion Nose w/ Local Cutaneous Skin Flap

Excision Skin Lesion

Excision Lipoma

Excision Lymph Nodes

Excision Mass

Excision Melanoma

Excision Neuroma Hand/Finger(s)

Excision Nevi

Removal Foreign Body (Foot/Hand)

LEVEL I (CORE) PRIVILEGES

(CON’T)

Excision (lunate, pisiform, scaphoid, exostosis finger)

Salivary Gland Biopsy/Excision

SOFT TISSUE REPAIRS / RECONSTRUCTIONS

Repair Laceration Earlobe

Revision Amputation Stump

Scar Revision (Burns, Keloids, Trauma)

Z-Plasty Hand

Soft Tissue Deficiencies

Pressure Sores

Lacerations

FLAPS AND GENERAL RECONSTRUCTION

Flap Debridement, Defatting, Delay, Cutaneous, Division-Inset of

Distant Pedicle Upper Extremity to Abdomen

Flap Island Pedicle Myocutaneous Forearm to hand (PIA)

Reconstruction Facial Defect with Flap (MOHS)

Reconstruction Lumbar Spine with Myocutaneous Flap

Scalp Reduction

Re-Exploration Flap Reconstruction (breast, sternum, upper and

lower extremity)

Excision Melanoma with Cutaneous Skin Flap

Release Frenulum (tongue tied)

Repair Ectropin

Local and Regional Flaps

GRAFTS (skin, fat, bone, fascia, cartilage, prosthetic)

Excision Basal Cell Carcinoma with STSG

Excision Lesion Skim with STSG

Excision Melanoma with STSG

REDUCTION FACIAL FRACTURE

Closed Reduction Nasal Fracture

ORIF (malar, orbital floor fracture, maxilla, mandible, zygoma)

Plastic Surgery Name:_______________________________________________ Page 2


LEVEL I (CORE) PRIVILEGES

(CON’T) HAND SURGERY/WRIST, GENERAL AND

RECONSTRUCTIVE

Manipulation Extremity

Ganglion Excision Upper & Lower Extremity

Release Contracture Finger(s)

Release Dorsal compartment Wrist

Excision Ganglion Cyst

Tenovaginectomy Finger(s)

Release Syndactyly Fingers and Toes

Fasciectomy Palmar & Digital (Dupuytren’s)

NERVE REPAIR / NEUROLYSIS / DECOMPRESSION /

TRANSPOSITION / GRAFT

Decompression Median Nerve Bilateral and Unilateral (Carpal

Tunnel)

Decompression Ulnar Nerve (Cubital Tunnel)

Neurolysis (digital, median, radial and ulnar nerve)

Repair Nerve (digital, median, radial and ulnar nerve

REMOVAL OF HARDWARE

Removal of Pin(s) Finger/Hand

Removal Plates & Screws Wrist

BODY CONTOURING

Liposuction (Adults)

Lipectomy

Lipolysis

RHYTIDECTOMY (Facial, Coronal, Neck)

Platysmoplasty

Rhytidectomy

PLASTY

Blepharoplasty

Correction Ptosis Eyelid, Single/Bilateral

Septorhinoplasty

Septoplasty

PLASTY (CON’T)

Rhinoplasty

Abdominoplasty (Adults)

Otoplasty, Unilateral/Bilateral

Labiaplasty (Adults)

MAMMOPLASTY

Augmentation Mammoplasty, Single/Bilateral

Capsulectomy/Capsulotomy Breast(s)

Mastectomy Immediate Reconstruction (Latissimus Flap

Free/Pedicle, Tissue Expander, TRAM Flap Free/Pedicle)

Reconstruction Areola/Nipple, Unilateral/Bilateral

Reconstruction Breast Bilateral (with Latissimus Pedicle Flap, with

Tissue Expander)

Reconstruction Breast Bilateral with TRAM Pedicle Flap

Reconstruction Breast Single (with Latissimus Pedicle Flap, with

Tissue Expander, with TRAM Pedicle Flap)

Mastopexy, Single/Bilateral

Reduction Mammoplasty, Single/Bilateral

Reduction Mammoplasty with Free Nipple Graft,

Bilateral/Unilateral

Removal Mammary Implant, Single/Bilateral

Removal Tissue Expander with Insertion Mammary Implant,

Single/Bilateral

Replace Mammary Implant, Unilateral/Bilateral

Excision Gynecomastia, Bilateral

TISSUE EXPANDER

Insertion, Removal, Replace Tissue Expander

LASER SURGERY

Excision Lesion Skin CO2, KTP, Nevi CO2

(Chest/Abdomen, Back/Hips, Face/Head, Neck, Upper and Lower

Extremity)

GENERAL COSMETIC

Chemical Peel and Dermabrasion, Facial/

Dermabrasion, Forehead

Hair Transplant, Flaps, Reduction

Tattoo Removal

Augmentation Chin (Implant)



LEVEL II PRIVILEGES Those procedures listed below, including those not listed in Level I,

which may require documentation of additional experience or training.

PHYSICIAN

REQUEST

Granted

Not

Granted*

With Following

Requirements** (Provide Details)


Reconstruction abdominal/ventral hernia repair

Reconstruction Cervical Spine with Myocutaneous Flap

Reconstruction Chest Wall with Latissimus Dorsi Pedicle Flap,

with Rectus Muscle Pedicle Flap, with TRAM Pedicle Flap

Reconstruction Lower Extremity with Myocutaneous Flap

Reconstruction Sternum Bilateral Cutaneous and Bilateral

Pectoral Flaps/Omentum, Rectus Muscle Flaps, TRAM Flaps

Reconstruction Sternum Bilateral Cutaneous and Unilateral

Pectoral Flaps, Rectus Muscle Flaps, TRAM Flaps

Reconstruction Upper Extremity with Latissimus Free Flap

Genital Reconstruction including vaginal (Hypospadius)

Hemartoma Surgery (Vascular malformations)

HAND JOINT / LIGAMENT SURGERY AND

RECONSTRUCTION

Amputation

Reconstruction Ligamentous Hand/Wrist

Synovectomy Carpal Bones, Interphalangeal Joint Finger(s) IPJ,

Wrist

REPAIR OR RELEASE TENDON / TENOLYSIS /

TENDON GRAFT AND TRANSFER

Repair Tendon Extensor Hand, Flexor Arm and Hand

Repair Tendons and Nerves Forearm, Finger(s), Hand, Wrist

Tendon Graft Upper Extremity

Tendon Transfer Hand/Wrist

Tenolysis Hand, Wrist (Dorsal Compartments), Wrist/Forearm

NERVE REPAIR

Decompression Median Nerve with Abductorplasty

Myelomeningocele repair (with Neurosurgery)

REDUCTION OF FRACTURE, DISLOCATIONS, HAND

AND WRIST

Closed Reduction Percutaneous Pinning Carpal(s), Metacarpal(s),

Wrist

ORIF Finger(s)

TREATMENT OF FACIAL DISEASES AND INJURIES

INCLUDING MAXILLOFACIAL STRUCTURES

Cleft Lip & Palate Surgery (Cleft lip, Cleft palate, Pharyngeal

Flap)

Nose Reconstruction (Cleft lip nasal deformity)

Ear Reconstruction (Microtia)

Eyelid Reconstruction

Head and Neck Surgery

Facial Fractures, including mandible

BONE CARTILAGE REMOVAL AND/OR GRAFTING,

AUTOLOGOUS & PROSTHETIC

Excision Tumor Hand

Fusion Scaphoid with Bone Graft Distal Radius, with Bone Graft

Iliac Crest

Graft Composite (Ear/Nose)

Harvest Bone Graft Iliac Crest

ORIF Scaphoid with Bone Graft Iliac Crest

ORIF Scapula



LEVEL II PRIVILEGES

(CON’T)

PHYSICIAN

REQUEST

Granted

Not

Granted*

With Following


Ostomy Wrist

Osteotomy Wrist with Bone Graft and Fixation

ARTHROPLASTY, ARTHRODESIS, ARTHROTOMY /

HAND AND WRIST

Arthrodesis Intercarpal Joint(s), Interphalangeal Joint(s) Finger,

Metacarpaophalangeal Joint(s) MCPJ

Arthroplasty Carpometacarpal Joint(s), Metacarpal Joint(s),

Wrist, Metatarsophalangeal Joint First Bilateral/Unilateral,

Metatarsophalangeal Joint First with Implant Bilateral/Unilateral

Arthroscopic Debridement Wrist, Removal Loose Bodies Wrist,

Repair Triangular Fibrocartilage Complex Tear Wrist,

Synovectomy Wrist

Arthroscopy Wrist

Arthrotomy Wrist Drainage Abscess

Capsulodesis Metacarpaophalangeal Joint(s), Wrist

Capsulotomy Carpal Bones, Interphalangeal Joints Finger(s) IPJ,

Metacarpaophalangeal Joint(s) MCPJ, Metatarsophalangeal

Joint(s) MTPJ, Wrist

Fusion Multiple Joint Hand

RECONSTRUCTION BONE OR JOINT DEFORMITY,

FACE, HANDS, WRISTS

Excision Bone Spur Hand

LASER SURGERY

Resurfacing Skin Facial Laser CO2

Vaporization Lesion Skin,/ Vascular Laser CO2/TD

(Back/Hip(s), Chest/Abdomen, Face/Head, Neck, Upper/Lower

Extremity)

ENDOSCOPIC

Decompression Median Nerve, Bilateral/Unilateral Endoscopic

(Carpal Tunnel), Endoscopic with Abductorplasty

Endoscopic Plastic Surgery Forehead, with Blepharoplasty

Upper/Lower Bilateral



MODERATE/CONSCIOUS SEDATION

PHYSICIAN

REQUEST

Granted

Not

Granted*

With Following

Requirements**

(Provide Details)

1. Providers seeking privileges in moderate/conscious sedation

must complete either the ASA sedation course – cost $199.00

(www.asahq.org/education/online-learning/safe-sedation-

training-moderate) or Medsimulation course – cost $75.00

(www.medsimulation.com) receiving a score of 85% or

above.

* Note: Providers completing the on-line training course

provided by Medsimulation from other institutions receiving

a score of 85% or higher will be accepted as an equivalent

measure of acceptable knowledge for sedation privileges.

2. Once the provider has successfully passed the course,

he/she must send the certificate of course completion to the

medical staff office via e-mail

([email protected]) or fax (859-5592 or

859-5593).

3. In addition to demonstrating medical knowledge

through completion of this course, providers must also

maintain airway management skills through current

completed training and certification in ACLS, ATLS or

PALS. (ACLS is offered through Kaleida Health Corporate

Clinical Education. Please call 716-859-5515 for

information. You can also take either course online if you

prefer. The following are just a few suggestions. You may

be able to obtain this training somewhere else:

https://promedcert.com/ $179.00,

www.buffalocpr.com/aclsatubcampus.html $135.00 or

www.wnyhe.com/courses/acls/ $175.00.)

4. After a four year period of privileging the provider must

repeat either the ASA sedation course or Medsimulation

course and receive a score of 85% or greater or a

comparable course reviewed and accepted by the Chief of

Anesthesiology. They must also maintain airway

management skills through completed and current training

and certification in ACLS, ATLS or PALS.



LEVEL III PRIVILEGES These procedures require documentation of a completed

Fellowship

PHYSICIAN

REQUEST

Granted

Not

Granted*

With Following



Reconstruction Chest Wall with Latissimus Dorsi Free Flap, with

Rectus Muscle Free Flap, with TRAM Free Flap

Reconstruction Cranium with Latissimus Free Flap and Rib Graft

Reconstruction Lower Extremity with Fascial Cutaneous Dorsal

Foot Free Flap, Upper Arm Free Flap, Forearm Free Flap

Reconstruction Lower Extremity with Latissimus Muscle Free

Flap, with Rectus Muscle Free Flap

Reconstruction Upper Extremity with Latissimus Free Flap, with

Rectus Muscle Free Flap, With Serratus Anterior Free Flap

Craniofacial Surgery/Orthognathic Surgery

Congenital Hand Reconstruction

Microvascular Surgery (DIEP flap breast reconstruction)

HAND SURGERY / WRIST, GENERAL AND

RECONSTRUCTIVE

Reimplantation, revascularization amputated hand/digit

MAMMOPLASTY

Reconstruction Breast Single/Bilateral with Latissimus Free Flap,

With TRAM Free Flap



KEY *NOT GRANTED DUE TO:

Provide Details Below

**WITH FOLLOWING REQUIREMENTS

Provide Details Below

1) Lack of Documentation 1) With Consultation

2) Lack of Required Training/Experience 2) With Assistance

3) Lack of Current Competence (Databank Reportable) 3) With Proctoring

4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define)

DETAILS:___________________________________________________________________________________________

____________________________________________________________________________________________________

National Practitioner Databank Disclaimer Statement

Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to

professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11101 et seq.)

___________________________________________/_________________

Signature of Applicant Date

_____ I approve of the procedures requested by the applicant: (a) _____ as requested (b) _____ as amended

_____ I, the Chief of Service, have consulted with the Chief of the Division of Pediatric Surgical Services (or designee)

concerning any requests of this applicant for Level II/III privileges on patients below the age of 18.

_________________________________________________/____________________

Signature of Chief of Service Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

Documents

DELINEATION OF PRIVILEGES - GENERAL SURGERY … · DELINEATION OF PRIVILEGES - GENERAL SURGERY ... Adults and Pediatrics Unless Specified ... Once the provider has successfully passed