Pediatrics KMC & SYC - Kettering Health Network

Pediatrics KMC & SYCDelineation of PrivilegesApplicant's Name:MembershipEducation/TrainingRequired QualificationsTo be eligible to apply for core privileges in pediatrics, the initial applicant must meet the followingcriteria:Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) - orAmerican Osteopathic Association (AOA)-accredited residency in pediatrics.ANDCurrent certification or active participation in the examination process, with achievement ofcertification within six years of completion of residency, leading to certification in pediatrics by theAmerican Board of Pediatrics or the American Osteopathic Board of Pediatrics.Clinical Experience (Initial) Applicants for initial appointment must be able to demonstrate provision of care, reflective of thescope of privileges requested, for at least 12 pediatric inpatients in the past 12 months, ordemonstrate successful completion of an ACGME- or AOA-accredited residency, clinicalfellowship, or research in a clinical setting within the past 12 months.Clinical Experience(Reappointment)Published: 4/9/2018To be eligible to renew core privileges in pediatrics, the applicant must document 40 Category IAMA or 40 category 1A and/or 2A CME hours and meet the following maintenance of privilegecriteria: Current demonstrated competence and an adequate volume of experience (20 patientPediatrics KMC & SYCPage 1 of 7

[applicant]encounters) with acceptable results, reflective of the scope of privileges requested, for the past 24months based on results of ongoing professional practice evaluation and outcomes. Evidence ofcurrent ability to perform privileges requested is required of all applicants for renewal of privileges.Residential Requirement:Published: 4/9/2018If called, all members of the Pediatric Clinical Service must be able to respond within 45 minutes.If on-call, the same response time (45 minutes) is in effect.Pediatrics KMC & SYCPage 2 of 7

[applicant]Pediatric Core PrivilegesDescription: This is not intended to be an all-encompassing list but rather reflective of the categories/types ofprocedures included in the core.Request all privileges listed below.RequestSYCKMC- Currently granted privilegesAdmit, evaluate, diagnose, treat, and provide consultation to patients from birth to young adulthood (21years of age) with acute and chronic disease including major complicated illnesses and routine newborncare. May provide care to patients in the intensive care setting in conformance with unit policies. Assess,stabilize, and determine disposition of patients with emergent conditions consistent with medical staffpolicy regarding emergency and consultative call services. The core privileges in this specialty include theprocedures on the attached procedure list and such other procedures that are extensions of the sametechniques and skills.Core ProceduresArthrocentesis and joint injectionAttendance at Delivery to Assume Care of Normal Newborns*Attendance at delivery of high risk newborns - emergent only*Burns, superficial and partial thicknessCardiac life support, including emergent cardioversion - emergent onlyEndotracheal intubation - emergent onlyFrenulectomyI & D abscessInsertion and management of chest tubes - emergent onlyLocal anesthetic techniquesManage uncomplicated minor closed fractures and uncomplicated dislocationsPerform simple skin biopsy or excisionPerform history and physical examPeripheral nerve blocksLigation of extra digitLumbar Puncture - emergent onlyPreliminary EKG interpretation - emergent onlyPlacement of anterior and posterior nasal hemostatic packingRemove non-penetrating foreign body from the eye, nose, or earSkin tag - ligationSuture uncomplicated lacerationsSuprapubic bladder tap - emergent onlyUmbilical catheterization - emergent onlyNeonatal-Perinatal Medicine Core Privileges*Description: *Not applicable to Sycamore Medical CenterQualificationsPublished: 4/9/2018Pediatrics KMC & SYCPage 3 of 7

[applicant]MembershipTo be eligible to apply for core privileges in neonatal-perinatal medicine, the initial applicant mustmeet the following criteria:Education/TrainingSuccessful completion of an Accreditation Council for Graduate Medical Education (ACGME)- orAmerican Osteopathic Association (AOA)-accredited fellowship in neonatal perinatalmedicine/neonatology.ANDCurrent subspecialty certification or actively pursuing subspecialty certification in leading tosubspecialty certification in neonatal-perinatal medicine by the American Board of Pediatrics or inneonatology by the American Osteopathic Board of Pediatrics.Clinical Experience (Initial) Applicants for initial appointment must be able to demonstrate provision of inpatient or consultativeservices, reflective of the scope of privileges requested, to at least 50 neonatal patients during thepast 12 months or demonstrate successful completion of an ACGME- or AOA-accreditedresidency, clinical fellowship, or research in a clinical setting within the past 12 months.Clinical Experience(Reappointment)To be eligible to renew core privileges in neonatal-perinatal medicine, the applicant mustdocument 40 Category I CME hours and meet the following maintenance of privilege criteria:Current demonstrated competence and an adequate volume of experience (20 neonatal patientencounters) with acceptable results, reflective of the scope of privileges requested, for the past 24months based on results of ongoing professional practice evaluation and outcomes. Evidence ofcurrent ability to perform privileges requested is required of all applicants for renewal of privileges.Additional QualificationsThese privileges are covered by an exclusive contract. Practitioners who are not a party to thecontract are not eligible to request the privilege(s), regardless of education, training, andexperience.Request all privileges listed below.RequestSYCKMC- Currently granted privilegesAdmit, evaluate, diagnose, treat, and provide consultation regarding newborns presenting with severeand complex life-threatening problems such as respiratory failure, shock, congenital abnormalities, andsepsis and provide consultation to mothers with high-risk pregnancies ( 32 wks). May provide care topatients in the newborn nursery and neonatal intensive care unit in conformance with unit policies.Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medicalstaff policy regarding emergency and consultative call services. The core privileges in this specialtyinclude the procedures on the attached procedure list and such other procedures that are extensions ofthe same techniques and skills.Core ProceduresAttendance at delivery of high risk newbornsBone marrow aspirationCardiac life support, including emergent cardioversionEndotracheal intubationExchange transfusionInsertion and management of central linesInsertion and management of chest tubesLumbar punctureParacentesis, thoracentesis, pericardiocentesisPublished: 4/9/2018Pediatrics KMC & SYCPage 4 of 7

[applicant]Perform history and physical examPeripheral arterial artery catheterizationPeritoneal dialysis with consultation as appropriatePost operative care of newbornsPreliminary EKG interpretationSuprapubic bladder tapUmbilical catheterizationVentilator care of infants beyond emerging stabilizationEcho*Description: These privileges are covered by an exclusive contract. Practitioners who are not a party to thecontract are not eligible to request the privilege(s), regardless of education, training, and experience. *Notapplicable to Sycamore Medical CenterQualificationsTo be eligible to apply for core privileges in transthoracic echocardiography, the initial applicantmust meet the following criteria:MembershipEducation/TrainingSuccessful completion of an Accreditation Council for Graduate Medical Education (ACGME) - orAmerican Osteopathic Association (AOA) - accredited residency in pediatrics.ANDSuccessful completion of an approved fellowship in Pediatric Cardiology.ANDSuccessful completion of a one year fellowship in pediatric echocardiography or in non-invasiveimaging or three year clinical experience reading pediatric echocardiograms.ANDCurrent subspecialty certification or actively pursuing subspecialty certification in leading tosubspecialty certification in neonatal-perinatal medicine by the American Board of Pediatrics or inneonatology by the American Osteopathic Board of Pediatrics.Clinical Experience (Initial) Applicants for initial appointment must be able to demonstrate provision of inpatient or consultativeservices, reflective of the scope of privileges requested, to at least 100 pediatric transthoracicechocardiography during the past 12 months or demonstrate successful completion of an ACGME- or AOA - accredited residency clinical fellowship, or research in a clinical setting within the past12 months.Clinical Experience(Reappointment)Current demonstrated competence and an adequate volume of experience (performance of 100pediatric cardiology patient encounters) with acceptable results, reflective of the scope ofprivileges requested, for the past 24 months based on results of ongoing professional practiceevaluation and outcomes. Evidence of current ability to perform privileges requested is required ofall applicants for renewal of privileges.Request all privileges listed below.RequestSYCKMC- Currently granted privilegesEchoPublished: 4/9/2018Pediatrics KMC & SYCPage 5 of 7

[applicant]Circumcision*Description: *Not applicable to Sycamore Medical CenterEducation/TrainingQualificationsSuccessful completion of formal training in this procedure, or the applicant must have completedhands-on training in this procedure under the supervision of a qualified physician preceptor.Evidence of having performed 2 proctored procedures during training.Clinical Experience (Initial) Demonstrated current competence and evidence of the performance of at least 2 procedures inthe past 12 months.Clinical Experience(Reappointment)Demonstrated current competence and evidence of the performance of at least 2 procedures inthe past 24 months based on results of quality assessment/improvement activities and outcomes.Request all privileges listed below.RequestSYCKMC- Currently granted privilegesCircumcisionAdministration of Sedation and AnalgesiaDescription: See Hospital Policy for Moderate SedationRequest all privileges listed below.RequestSYCKMC- Currently granted privilegesModerate SedationAcknowledgment of ApplicantI have requested only those privileges for which by education, training, current experience, and demonstrated competency Ibelieve that I am competent to perform and that I wish to exercise at Kettering Medical Center and Sycamore Medical Centerand I understand that:A. In exercising any clinical privileges granted, I am constrained by applicable Hospital and Medical Staff policies and rulesapplicable generally and any applicable to the particular situation.B. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actionsare governed by the applicable section of the Medical Staff Bylaws or related documents.Published: 4/9/2018Pediatrics KMC & SYCPage 6 of 7

[applicant]Practitioner's SignatureDateClinical Service Chief Recommendation - PrivilegesI have reviewed the requested clinical privileges and supporting documentation and make the following recommendation(s):Recommend all requested privilegesDo not recommend any of the requested privilegesRecommend privileges with the following conditions/modifications/deletions (listed lanationClinical Service Chief Recommendation - Additional CommentsClinical Service Chief SignatureDateSubmitPublished: 4/9/2018Pediatrics KMC & SYCPage 7 of 7

Pediatrics KMC & SYC Delineation of Privileges Applicant's Name: Instructions: 1. Click the Request checkbox to request a group of privileges. 2. Uncheck any privileges you do not want to request in that group.