General Internal Medicine Clinical Privileges
Name: ______
Effective from ______/______/______to ______/______/______
□❏Initial privileges (initial appointment) ❏□❏ Renewal of privileges (reappointment)
All new applicants must meet the following requirements as approved by the governing body, effective: ____/____/____.
If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC].
Definition: An Internist is a specialist trained in the diagnosis and treatment of a broad range of diseases in adults involving all organ systems, and is proficient in the medical management of patients who have undifferentiated or multi-system disease processes. An Internist cares for hospitalized and ambulatory patients and may play a role in teaching or research.
Applicant: Check 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/chief]: Check the appropriate box for recommendation on the last page of this form and include your recommendation for focused professional practice evaluation.[1]If recommended with conditions or not recommended, provide the condition or explanation on the last page of this form.
Other requirements
• Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficient space, equipment, staffing, and other resources required to support the privilege.
• This document is focused on defining qualifications related to competency 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 general internal medicine
Initial privileges: To be eligible to apply for privileges in internal medicine, the applicant must meet the following criteria:
Current certification in General Internal Medicine by the Royal College of Physicians and Surgeons of Canada or possession of equivalent credentials acceptable to both the College of Physicians and Surgeons of British Columbia and the governing body (organization name).
AND
Required current experience: Provision of acute care for three months a year averaged over two years reflective of scope of privileges requested or successful completion of a RCPSC accredited residency or clinical fellowship within thepast 12 months.
Renewal of privileges: To be eligible to renew privileges in internal medicine, the applicant must meet the following criteria:
Current demonstrated competence and an adequate volume of experience (three months a year averaged over three years) with acceptable results reflective of the scope of privileges requested. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewalof privileges. Adherence to the requirements of the Medical Staff Bylaws and Medical Staff Rules, including the requirement to participate equitably in an on call schedule.
Core privileges: Internal medicine
❑ Requested Admit, evaluate, diagnose, treat, and provide consultation to adult patients with acute, chronicand complex illnesses, diseases and disorders of the cardiovascular, respiratory, endocrine, metabolic, musculoskeletal, neurological,hematopoietic, gastroenteric, renal, and genitourinary systems1. May provide care to patients incritical/acute care settingsin conformance with unit policies. May provide care to patients with malignancies, infectious and pregnancy related diseases. Assess, stabilize, and determine the disposition of patients with emergent conditionsconsistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialtyinclude the procedures on the attached procedures list and such other procedures that are extensions of the sametechniques and skills.
Core procedures list
This is not intended to be an all-encompassing procedures list. It defines the types of activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.
• Performance of history and physical exam
Interpretation of electrocardiograms
• Abdominal paracentesis
• Arthrocentesis and joint injections
• Drawing of arterial blood
• Insertion and management of central venous catheters and arterial lines
• Local anesthetic techniques
• Performance of simple skin biopsy
Cardiac stress testing (currency to be determined[JS1])
Lumbar puncture
• Thoracentesis[JS2] and insertion of chest tube1
- Cardioversion emergent and elective[JS3]
- Holter/event monitor[JS4]
- Invasive and non-invasive mechanical ventilation[JS5](currency to be determined)
Special Non-core Privileges (See Specific Criteria)
Non-core privileges are requested individually in addition to requesting the core. Each individual requesting non-core privileges must meet the specific threshold criteria as applicable to the applicant.
Non-core privileges: • Excision of skin and subcutaneous tumors, nodules, and lesions
Non-core privileges: Exercise testing—treadmill[JS6]
❑ Requested
Initial privileges: Successful completion of a RCPSC accredited residency in internal medicine that included a minimum of four weeks or the equivalent of training in the supervision and interpretation of exercise testing and evidence that the training included participation in at least 50 exercise procedures.
AND
Required current experience: Demonstrated current competence and evidence of the performance of at least 25 exercise tests in the past 12 months or completion of training in the past 12 months.
Renewal of privileges: Demonstrated current competence and evidence of the performance of at least 75 exercise tests in the past 36 months based on results of ongoing professional practice evaluation and outcomes.
Source: American College of Cardiology, American Heart Association, American College of Physicians—American Society Internal Medicine task force on clinical competence, May 2000.
Non-core privileges: Bone marrow biopsy
❑ Requested
Initial privileges: Successful completion of Royal College of Physicians and Surgeons of Canada (or equivalent acceptable to the College of Physicians and Surgeons of British Columbia) postgraduate training in general internal medicine that included training in bone marrow biopsy.
AND
Required current experience: Demonstrated current competence and evidence of the performance of 5 bone marrowbiopsies annually averaged over three years
Renewal of privileges: Demonstrated current competence and evidence of the performance of 5 bone marrowbiopsies annually averaged over three years based on results of ongoing professional practice evaluation and outcomes.
Non-core Privileges: Ventilator Management (not complex including CPAP – up to 36 hours[JS7])
❑ Requested
Initial privileges: For ventilator cases not categorized as complex* (up to 36 hours), successful completion of a RCPSC (or equivalent) accredited post graduate training program that provided the necessary cognitive and technical skills (basic training) for ventilator management not categorized as complex.
*Complex is defined as more than 36 hours; PEEP requirement ³ 10 cm of water; FI02 requirement ³ 0.6; static plateau pressure ³ 30 cm of water; presence of significant preexisting pulmonary disease; multi-system organ failure; chronic ventilator dependence; patient not meeting previous criteria, but clinical condition deteriorating.
AND
Required current experience: Demonstrated current competence and evidence of the management of at least [n] mechanicalventilator cases (e.g., not complex) in the past 12 months or completion of training in the past 12 months.
Renewal of privileges: Demonstrated current competence and evidence of the management of at least [n] mechanicalventilator cases (e.g., not complex) in the past 24 months based on results of ongoing professional practice evaluation andoutcomes.
Source: California Thoracic Society position paper, “Clinical Privileges for Mechanical Ventilator Management.” April 1, 2008.
Other non-core
- Echocardiography (in consultation with DI and Cardiology)
- Endoscopy (in consultation with GI, General Surgery and GP)
- Bronchoscopy (in consultation with Respirology and ENT)
- Pulmonary Function Studies (in consultation with Respirology)
- Hemodialysis (set up teleconference Adeera and Abdalla)
- Liver bx (in consultation with GI/DI)
- Bedside ultrasound (in consultation with Emergency Medicine, critical care and Dr. Wong)
Other emergency procedures
- Temporary pacemaker insertion[JS8]
Non-core privileges: Administration of sedation and analgesia
❑ Requested
See “Hospital Policy for Sedation and Analgesia by Nonanesthesiologists.”
Acknowledgment of practitioner
I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at [hospital name], and I understand that:
a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable 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 actions are governed by the applicable section of the medical staff bylaws[JS9] or related documents.
Signed ______Date ______
[Department chair/chief]’s recommendation
I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and:
❑Recommend all requested privileges
❑Recommend privileges with the following conditions/modifications:
❑Do not recommend the following requested privileges:
Privilege Condition/modification/explanation
Notes: ______
______
______
______
[Department chair/chief] signature ______Date ______
FOR MEDICAL STAFF USE ONLY
Credentials committee action Date ______
Medical executive committee action Date ______
Board of trustees action Date ______
References
1.Objectives of Training in the Subspecialty of General Internal Medicine. Accessed 23 Feb 2013.
[1]1. For Joint Commission–accredited hospitals only.
[JS1]Currency three months per year in a practice where stress testing is part of the regular pattern of practice averaged over three years. Return to currency supervised conduct of 20 stress tests with a cardiac teaching service
[JS2]reference gim subspecialty
[JS3]Currency three months a year in a practice that includes cardioversion averaged over three years. Return to currency one week on a cardiology teaching service.
[JS4]As per stress testing
[JS5] Currency 3 months per year averaged over three years in a practice that includes critical care. If there is a need for a specific number – how many ventilated patients?
How does someone return to currency? ? two weeks supervised in a tertiary ICU setting.
[JS6]Held here to guide currency discussion
[JS7]Held here to guide currency discussion
[JS8]Identified as a need for simulation training
Perhaps having done one, followed by current practice in inserting CV lines
[JS9]Check WHO website for currency information