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1 core Privileges for Physicians A Practical Approach to Developing and Implementing Criteria-Based Privileges Sixth Edition Sally Pelletier, CPMSM, CPCS. Contributors: Gina Leeds, CPMSM. Mary Hoppa, MD, MBA. core Privileges Physicians for A Practical Approach to Developing and Implementing Criteria-Based Privileges Sixth Edition Sally Pelletier, CPMSM, CPCS. Contributors: Gina Leeds, CPMSM. Mary Hoppa, MD, MBA. core Privileges for Physicians, Sixth Edition, is published by HCPro, a division of BLR. Copyright 2014 HCPro, a division of BLR. All rights reserved. Printed in the United States of America.

2 5 4 3 2 1. ISBN: 978-1-55645-125-6. No part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have received an unauthorized copy. HCPro provides information resources for the healthcare industry. HCPro is not affiliated in any way with The joint commission , which owns the JCAHO and joint commission trademarks. Sally J. Pelletier, CPMSM, CPCS, Author Gina Leeds, CPMSM, Contributor Mary J. Hoppa, MD, MBA, Contributor Karen Kondilis, Editor Adrienne Trivers, Product Manager Erin Callahan, Senior Director, Product Elizabeth Petersen, Vice President Matt Sharpe, Production Supervisor Vincent Skyers, Design Manager Vicki McMahan, Sr.

3 Graphic Designer Jason Gregory, Layout/Graphic Design Kelly Church, Cover Designer Advice given is general. Readers should consult professional counsel for specific legal, ethical, or clinical questions. Arrangements can be made for quantity discounts. For more information, contact: HCPro 75 Sylvan Street, Suite A-101. Danvers, MA 01923. Telephone: 800-650-6787 or 781-639-1872. Fax: 800-639-8511. Email: Visit HCPro online at: and Contents About the vii Introduction to the core Privilege xi Section 1: Specialty core 1. Allergy/Immunology Clinical Anesthesiology Clinical Colon and Rectal Surgery Clinical Dentistry Clinical Dermatology Clinical Emergency Medicine Clinical Family Medicine Clinical General Surgery Clinical Genetics Clinical Internal Medicine Clinical Neurological Surgery Clinical Neurology Clinical Nuclear Medicine Clinical Obstetrics and Gynecology Clinical Ophthalmology Clinical 133.

4 core Privileges for Physicians, Sixth Edition 2014 HCPro iii Contents Oral And Maxillofacial 141. Orthopedic Surgery Clinical 149. Otolaryngology Clinical 167. Pathology Clinical 174. Pediatric Clinical 184. Physical Medicine and Rehabilitation Clinical 192. Plastic Surgery Clinical 199. Podiatry Clinical Psychiatry Clinical 218. Radiation Oncology 228. Radiology Clinical 234. Thoracic Surgery Clinical 250. Urology Clinical 259. Section 2: Subspecialty core Adolescent Medicine Clinical 270. Cardiac Surgery Clinical 274. Cardiovascular Disease (Cardiology) Clinical 284. Complex General Surgical Oncology Clinical 302.

5 Critical Care Clinical 308. Developmental/Behavioral Pediatrics Clinical 313. Endocrinology, Diabetes, and Metabolism Clinical 317. Gastroenterology Clinical 321. Geriatric Medicine Clinical 327. Hematology/Medical Oncology Clinical 331. Hospice and Palliative Medicine Clinical 338. Hyperbaric Medicine Clinical 342. Infectious Disease Clinical 347. Medical Toxicology Clinical 353. Neonatal/Perinatal Medicine Clinical 357. Nephrology Clinical 362. iv 2014 HCPro core Privileges for Physicians, Sixth Edition Contents Neurodevelopmental Disabilities Clinical 371. Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine Clinical Privileges .

6 375. Occupational Medicine Clinical 379. Pain Medicine Clinical 384. Pediatric Anesthesiology Clinical 391. Pediatric Cardiology Clinical 396. Pediatric Cardiothoracic Surgery Clinical 405. Pediatric Critical Care Medicine Clinical 412. Pediatric Dentistry Clinical 417. Pediatric Dermatology Clinical 423. Pediatric Emergency Medicine Clinical 427. Pediatric Endocrinology Clinical 433. Pediatric Gastroenterology Clinical 437. Pediatric Hematology/Oncology Clinical 444. Pediatric Infectious Diseases Clinical 449. Pediatric Nephrology Clinical 453. Pediatric Neurosurgery Clinical 459. Pediatric Ophthalmology Clinical 465.

7 Pediatric Orthopedic Surgery Clinical 473. Pediatric Otolaryngology Clinical 481. Pediatric Pulmonology Clinical 486. Pediatric Radiology Clinical 492. Pediatric Rehabilitation Medicine Clinical 503. Pediatric Rheumatology Clinical 508. Pediatric Surgery Clinical 512. Pediatric Urology Clinical 521. Pulmonary Disease Clinical 529. Rheumatology Clinical 535. Sleep Medicine Clinical 540. Sports Medicine Clinical 544. Surgery of the Hand Clinical Privileges .. 548. core Privileges for Physicians, Sixth Edition 2014 HCPro v Contents Surgical Critical Care Clinical 554. Urgent Care Center Clinical 561.

8 Vascular Surgery Clinical 565. vi 2014 HCPro core Privileges for Physicians, Sixth Edition About the Authors Sally J. Pelletier, CPMSM, CPCS. Sally J. Pelletier, CPMSM, CPCS, is an advisory consultant and the chief credentialing officer for The Greeley Company, Inc., in Danvers, Massachusetts. She brings more than 20 years of credentialing and privileging experience to her work with medical staff leaders and MSPs across the nation. Pelletier advises clients in the areas of accreditation, regulatory compliance, credentialing, privileging , onboarding process simplification and redesign, and medical staff services department operations, and also provides leadership and development training for medical staff leaders and MSPs.

9 She currently serves on the editorial advisory board of the Credentialing Resource Center Journal and Medical Staff Briefing for HCPro, a division of BLR. Pelletier performs as an expert witness, and presents at state and national seminars on a variety of topics related to medical staff leadership training, leading practices in credentialing and privileging , and practitioner competency management, and is faculty for The Greeley Institute for Medical Services Professional Development and The Greeley Credentialing Solution. She has coauthored several HCPro and Greeley books, including The Medical Staff's Guide to Overcoming Competence Assessment Challenges (2013); core Privileges for AHPs: Develop and Implement Criteria- Based privileging for Non-Physician Practitioners, Second Edition (2011); core Privileges for Physicians: A Practical Approach to Developing and Implementing Criteria-Based Privileges , Fifth Edition (2010).

10 core Privileges for Physicians, Sixth Edition 2014 HCPro vii About the Authors Assessing the Competency of Low-Volume Practitioners: Tools and Strategies for OPPE & FPPE Compliance, Second Edition (2009); The FPPE Toolbox: Field-Tested Documents for Credentialing, Competency, and Compliance (2008); and Converting to core privileging : 10 Essential Steps to a Criteria-Based Program (2007). She has served as secretary and as the Northeast region representative on the board of directors for the National Association Medical Staff Services (NAMSS). Other leadership roles for NAMSS have included serving as a NAMSS instructor; and chairing the Governance, Management, and Manpower Committee.