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«UNMH Ophthalmology Clinical Privileges Name: Effective Dates: From To _ All new applicants must meet the following requirements as approved by the ...»

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UNMH Ophthalmology Clinical Privileges

Name:____________________________ Effective Dates: From __________ To ___________

All new applicants must meet the following requirements as approved by the UNMH Board of Trustees,

effective April 29, 2016:

INSTRUCTIONS:

Applicant: Check off the “requested” box for each privilege requested. Applicants have the burden of

producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.

Department Chair: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation.

OTHER REQUIREMENTS:

1. Note that privileges granted may only be exercised at UNM Hospitals and clinics that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in hospital or department policy.

2. This document defines qualifications to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.

QUALIFICATIONS FOR OPHTHALMOLOGY

Initial Privileges: To be eligible to apply for privileges in ophthalmology, the applicant must meet the

following criteria:

1. Successful completion of an ophthalmology residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA);

AND

2. Current certification or active participation in the examination process leading to certification in ophthalmology by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology-Head and Neck Surgery; AND

3. Required current experience: An adequate number of ophthalmologic procedures, reflective of the scope of privileges requested, during the past twelve (12) months, or successful completion of an ACGME or AOA accredited residency or clinical fellowship within the past twelve (12) months.

Renewal of Privileges: To be eligible to renew privileges in ophthalmology, the applicant must continue to meet appointment criteria and must meet the following maintenance of privilege criteria: Current demonstrated competence and an adequate volume of experience, with a results reflective of the scope of privileges requested, for the past twenty-four (24) months based on ongoing professional practice evaluation and outcomes. Evidence of current physical ability to perform privileges requested is required of all applicants for renewal of privileges.

Practice Area Code: 40 Version Code: 04-2016

–  –  –

Name:____________________________ Effective Dates: From __________ To ___________ CORE PRIVILEGES: Ophthalmology Admit, evaluate, diagnose, treat and provide consultation, order diagnostic studies and procedures, and perform surgical and non-surgical procedures on patients of all ages with ocular and visual disorders, the eye and its component structures, the eyelids, the orbit and the visual pathways. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the below noted procedure list and such other procedures that are extensions of the same techniques and skills.

–  –  –

This list is a sampling of procedures included in the ophthalmology core. This is not intended to be an allencompassing list, but rather reflective of the categories/ types of procedures included in the core.

To the applicant: If you wish to exclude any procedures listed in the core, strike through then initial and date those procedures you do not wish to request.

1. Performance of history and physical examination.

2. A and B mode ultrasound examination.

3. Anterior limbal approach or pars plana automated vitrectomy.

4. Conjunctiva surgery, including grafts, flaps, tumors, pterygium, pinguecula.

5. Corneal surgery, including laceration repair, diathermy, traumatic repair, including refractive surgery but excluding keratoplasty and keratotomy.

6. Corneal/scleral laceration repair.

7. Cryotherapy for ciliary body for uncontrolled painful glaucoma.

8. Glaucoma surgery with intraoperative/postoperative antimetabolite therapy, primary trabeculectomy surgery, thermal sclerostomy, and posterior lip sclerectomy, reoperation, Seton/Tube surgery.

9. Injection of intravitreal medications.

10. Cataract surgery: intra and extracapsular cataract extraction with or without lens implant, or phacoemulsification.

11. Laser peripheral iridotomy, trabeculoplasty, pupilo/gonioplasty, suture lysis. Pan-retinal photocoagulation, macular photocoagulation, repair of retinal tears, capsulotomy, cyclophotocoagulation, sclerostomy, lysis.





12. Lid and ocular adnexal surgery, including plastic procedures, chalazion, ptosis, repair of malposition, repair of laceration, blepharospasm repair, tumors, flaps, enucleation, evisceration.

13. Nasolacrimal surgery, including dacryocystectomy, dacryocystorhinostomy, excision of lacrimal sac mass, probing and irrigation, balloon dacryoplasty.

14. Oculoplastic/orbit surgery, including removal of the globe and contents of the orbit, exploration by lateral orbitotomy, exenteration, blowouts, rim repairs, tumor and foreign body removal.

15. Removal of anterior and/or posterior segment foreign body.

Practice Area Code: 40 Version Code: 04-2016 2 UNMH Ophthalmology Clinical Privileges Name:____________________________ Effective Dates: From __________ To ___________

16. Removal of chalazion and other minor skin and eyelid lesions.

17. Retrobulbar or peribulbar injections for medical delivery or chemical denervation for pain control.

18. Strabismus surgery.

19. Use of local anesthetics and parenteral sedation for ophthalmologic conditions.

SPECIAL NON-CORE PRIVILEGES

If desired, non-core privileges are requested individually in addition to requesting the core privileges.

Each individual requesting non-core privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required, experience, and maintenance of clinical competency.

QUALIFICATIONS FOR USE OF LASER:

Criteria: To be eligible to apply for use of laser, the applicant must meet the following criteria:

1. Successful completion of an approved residency in a specialty or subspecialty which included training in laser principles or completion of an approved eight to ten (8-10) hour minimum CME course which includes training in laser principles. In addition, applicant should spend time after the basic training course in a clinical setting with an experience operator who has been granted laser privileges acting as a preceptor.

2. Practitioner agrees to limit practice to only the specific laser types for which he/she has provided documentation of training and experience.

3. Practitioner must supply a certificate documenting that he/she attended a wavelength and specialty-specific laser course and must also present documentation as to the content of that course.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of requested procedures with acceptable outcomes in the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of requested procedures with acceptable outcomes in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes.

–  –  –

Name:____________________________ Effective Dates: From __________ To ___________

QUALIFICATIONS FOR PHOTOREFRACTIVE KERATECTOMY:

Criteria: To be eligible to apply for clinical privileges in photorefractive keratectomy, the applicant must

meet the following criteria:

1. Successful completion of an ACGME or AOA accredited residency program in ophthalmology, followed by a fellowship or experience in refractive or corneal surgery; AND

2. Successful completion of an FDA-approved postgraduate PRK course.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of photorefractive keratectomy procedures with acceptable outcomes in the past twelve (12) months or completion of training within the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of photorefractive keratectomy procedures with acceptable outcomes in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes.

–  –  –

Requested

QUALIFICATIONS FOR PHAKIC INTRAOCULAR LENS (IOL) IMPLANT SURGERY:

Criteria: To be eligible to apply for clinical privileges in phakic intraocular lens (IOL) implant surgery, the

applicant must meet the following criteria:

1. Successful completion of an ACGME or AOA accredited residency program in ophthalmology; AND

2. Successful completion of a formal training course in phakic IOL implant surgery.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of IOL surgery procedures with acceptable outcomes in the past twelve (12) months or completion of training within the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of IOL surgery procedures with acceptable outcomes in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes. In addition, continuing medical education related to phakic IOL implant surgery shall be required.

NON-CORE PRIVILEGES: Phakic Intraocular Lens (IOL) Implant Surgery Name:____________________________ Effective Dates: From __________ To ___________

QUALIFICATIONS FOR CORNEAL RING IMPLANTS:

Criteria: To be eligible to apply for clinical privileges in corneal ring implants, the applicant must meet the

following criteria:

1. Successful completion of an ACGME or AOA accredited residency program in ophthalmology; AND

2. Successful completion of an approved course in corneal ring implant procedures; AND

3. Performance of an adequate number of corneal ring implants with acceptable results, the first five (5) of which were performed under supervision of an experienced surgeon.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of corneal ring implants with acceptable outcomes in the past twelve (12) months or completion of training within the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of corneal rings implants with acceptable outcomes in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes.

–  –  –

Requested

QUALIFICATIONS FOR CORNEAL TRANSPLANTS (PENETRATING KERATOPLASTY):

Criteria: To be eligible to apply for clinical privileges in corneal transplants (penetrating keratoplasty), the

applicant must meet the following criteria:

1. Successful completion of an ACGME or AOA accredited residency program in ophthalmology.

2. If residency training did not include performing corneal transplants, applicant must have completed a training program that included performing corneal transplants.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of corneal transplant procedures with acceptable outcomes in the past twelve (12) months or completion of training within the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of corneal transplant procedures with acceptable outcomes in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes.

NON-CORE PRIVILEGES: Corneal Transplants (Penetrating Keratoplasty) Name:____________________________ Effective Dates: From __________ To ___________

QUALIFICATIONS FOR RETINA AND VITREOUS SURGERY:

Criteria: To be eligible to apply for clinical privileges in retina and vitreous surgery, the applicant must

meet the following criteria:

1. Successful completion of an ACGME or AOA accredited residency program in ophthalmology; AND

2. Successful completion of a fellowship in vitreo retinal surgery or the equivalent training and experience.

Required Current Experience: Demonstrated current competence and evidence of the performance of an adequate number of retina and vitreous surgery procedures with acceptable outcomes, reflective of the scope of privileges requested, in the past twelve (12) months or completion of training within the past twelve (12) months.

Reappointment Requirements: Demonstrated current competence and evidence of the performance of an adequate number of retina and vitreous surgery procedures with acceptable outcomes, reflective of the scope of privileges requested, in the past twenty-four (24) months based on results of ongoing professional practice evaluation and outcomes.



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