S02 AMENDMENT 0001 - 36C25724Q0141.docx

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer)

36C257 Department of Veterans Affairs VHA RPO West NCO 17 El Paso Contracting Office 11495 Turner Road El Paso TX 79936

SEE BLOCK 6

To all Offerors/Bidders

36C25724Q0141 01-17-2024

X

The purpose of this amendment is to post the questions and answers received for this solicitation.

All other terms and conditions remain unchanged.

NOEL E. RAMIREZ

Contracting Officer

VA-VHA-RPOW-2023-0030

CONTINUATION PAGE

CENTRAL TEXAS OPERATIVE UROLOGY PHYSICAN SERVICES

QUESTIONS AND ANSWERS

1. How many other Urologists on staff?

A: For the Temple facility 1 of 3 FTE currently filled

1. What support staff is available?

A: 1 PA, 1 NP and 3 Nursing Staff

1. How many clinic patients per day per provider?

A: Approximately 13 slots for clinical patients

1. Approximately how many surgeries per week?

A: Approximately 4 surgeries per week

1. Will the provider be expected to round on their own patients if admitted?

A: Yes

1. Is rounding done every morning?

A: Yes

1. Is rounding expected on the weekends?

A: Yes

1. Typically, what is the length of hospital stay after surgery?

A: Average of 4 days

1. What is the call rotation?

A: Every other week

1. What specific procedures are required?

A:

1. What specific surgeries are required?

A:

1. How long does it typically take to credential with your VA location?

A: Approximately 90 to 120 days

13. Does the solicitation strictly require one (1) urologist during normal business hours and another (1) after business hours and weekends?

A: No, 1 provider for all

14. Are we allowed to propose under the solicitation terms, two different urologists with equal working hours covering the requirement? Specifically, each physician covering 1040 hours of daytime shift and 618 hours of on-call hours?

A: No, we can take 2 full time but no-part time providers

15. B2 Schedule of Services shows CLIN 0002, 1002, 2002 OFF-HOURS COVERAGE / ON CALL: On-call contractor’s physician(s) must be available at all times for phone consultations with VA residents and physicians. On-call providers must be available within 15 minutes by phone and on-site, within 60 minutes.

· Will the government please adjust the B2, if there is an “On Call” rate the government also needs to provide a CLIN for “Call Back” to account for this portion of the rate?

A: No, call back is a part of “On Call”.

16. B3 PWS 1.4.3 states - The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following: VHA Directive 1065: Productivity and Staffing Guidance for Specialty Provider Group Practice.

· Can the government remove this Directive as this is a FFP IDIQ not a contract for a group practice?

A: No, it’s a National Requirement

17. B3 PWS 1.4 states - The contractor shall be subject to the following policies, including any subsequent updates during the period of performance. The policies listed below can be accessed electronically at the following:

VHA Directive 1400.01: Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents and VHA Handbook 1400.04: Supervision of Associated Health Trainees. - REMOVED

Additionally, PWS 4 Contractor Responsibilities States 4.3 EDUCATION AND SUPERVISION OF HEALTH PROFESSIONS TRAINEES (HPTS): Education and Supervision of HPTs: Per the guidelines dictated by the VA Office of Academic Affiliations (OAA) Directives and health professions education (HPE) accrediting agencies, the contractor performing the services of the contract will be responsible for the education and supervision of health professions trainees. Contract Provider shall be responsible for:

Education of HPTs: Contractor shall provide an academic environment conducive to the training and professional development of HPTs rotating through the Urology Service in accordance with current VA, accrediting agency, and JC equivalent compliance guidelines. Contractor shall meet the educational objectives of the training program as outlined in the program letter of agreement. Contractor may provide practice-based learning opportunities and/or didactic teaching to HPTs.

Supervision of HPTs: Contractor shall provide supervision of HPTs in accordance with current VA, accrediting agency, and JC equivalent compliance guidelines. Contractor shall ensure HPT supervision in accordance with VHA Directive 1400.01, Supervision of Physician, Dental, Optometry, Chiropractic, and Podiatry Residents, and VHA Handbook 1400.04, Supervision of Associated Health Trainees. Contractor shall be responsible for overseeing HPTs’ acquisition and demonstration of knowledge, skills, attitudes, and professionalism while the HPT participates in patient care. Contractor shall be responsible for periodic evaluation of HPTs and the training program as required by accrediting agencies and program letters of agreement. Contractor shall be responsible for ensuring that all notes and encounters are completed, clearly demonstrate the involvement of the supervising practitioner, and comply with VA standards, equivalent to JC compliance guidelines, standard commercial practice and guidelines established by VHA Directive 1400.01 and VHA Handbook 1400.04. The Contractor shall also perform any administrative duties relative to documentation of HPT training, as required and directed by the VA COS or designated representative.

· This is a Non-Personal Services Contract outlines in PWS 2.3 as such the contractor cannot have oversight of residents and/or take on Inherently Government Functions outlined in PWS 2.6. We request the government remove all reference to oversight and supervision.

A: This section has been removed, please disregard this section.

END OF QUESTIONS AND ANSWERS

Urology DRAFT 2022.doc

Central Texas Veterans Health Care System

SURGICAL SERVICE

Urology Core Clinical Privileges

PRIVILEGES REQUESTED BY:

To be eligible to apply for core privileges in Surgical Service, the applicant must meet the following qualifications unless otherwise grand fathered prior to July 1, 2008:

Background: the urology surgeon is an individual who specialize in treat surgical or medical management in the following areas: Medical and surgical disorders of the genitourinary system; the adrenal gland and including endoscopic, percutaneous, and open surgery of congenital and acquired conditions of the urinary and reproductive systems and the contiguous structures .surgical oncology (including coordinated multimodality management of the cancer patient by screening, surveillance, surgical adjunctive therapy, rehabilitation, and follow-up); management of trauma, including ischemic pain, gangrene, infections, and tumors. The responsibility for all phases of care of the injured patient is an essential component of general surgery; as well as complete care of critically ill patients with underlying surgical conditions in emergency departments and intensive care units.

Education: Must hold a doctor of medicine or doctor of osteopathy degree as described in VA Handbook 5005.

Minimum Formal Training: Successful completion of an approved residency in urology ACGME- or AOA-accredited post-graduate training program in Urology

Licensure: Must hold a current, valid, unrestricted license at all times.

Basic Life Support: Expected current certification as defined in station policy.

Certification: Current certification or active participation in the examination process leading to certification in the American Board of Urology or the American Osteopathic Board of Urology preferred but not required.

Required Previous Experience: Applicants for initial appointment may be requested to provide documentation of the number and types of hospital cases during the past 24 months. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, and other qualifications and for resolving any doubts.

Maintenance of Privilege: To be eligible to renew core privileges in Urology Surgery, the applicant must meet the following Maintenance of Privilege Criteria: Current demonstrated competence and an adequate volume of experience with acceptable results in the privileges requested for the past 24 months based on results of quality assessment/improvement activities and outcomes.

urology Core Privileges

(Please mark with initials)

__Requested Admit, evaluate, diagnose, and provide consultation and therapeutic treatments to inpatients and outpatients of all ages, except as specifically excluded from practice, with Privileges include admission, consultation, work-up, preoperative, operative, and postoperative care to correct or treat various conditions, illnesses, and injuries of the alimentary tract; abdomen and its contents; breasts, skin, and soft tissue; head and neck; vascular system (excluding the intracranial vessels, the heart, and those vessels intrinsic and immediately adjacent thereto); endocrine system; and extremity surgery (biopsy, I&D, varicose veins, foreign body removal, skin grafts, amputations).

Core General Surgery Privileges: Clinical privileges in the operative & perioperative care of diseases involving the alimentary tract; abdomen and its contents (including diaphragm); breast, skin, & soft tissue; head & neck; vascular system (excluding the intracranial vessels, the heart, & those vessels intrinsic & immediately adjacent thereto); endocrine system, basic laparoscopic procedures (i.e., laparoscopic appendectomy, laparoscopic cholecystectomy, & diagnostic laparoscopy); & minor extremity surgery (i.e., biopsy, I&D, varicose veins, foreign body removal, & skin grafts

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

MODIFICATION(S)

RECOMMEND

DISAPPROVAL

Urology Core Procedure List:

All forms of prostate ablation

All forms of prostatectomy including biopsy

Anterior pelvic exenteration

Appendectomy as component of urologic procedure

Bladder instillation treatments for benign and malignant disease

Bowel resection as component of urologic procedure

Circumcision

Closure evisceration

Continent reservoirs

Creation of neo-bladders

Cystolithotomy

Cystoscopy

Enterostomy as component of urologic procedure

Excision of retroperitoneal cyst or tumor

Exploration of retroperitoneum

Extracorporeal shock wave lithotripsy

Hysterectomy, bilateral salpingoophorectomy in connection with cystectomy

Inguinal herniorrhaphy as related to urologic operation

Insertion/removal of ureteral stent

Intestinal conduit

Lararoscopic surgery, urologic for disease of urinary tract

Laparotomy for diagnostic or exploratory purposes (urologic related conditions)

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

Lymph node dissection-inguinal, retroperitoneal, or pelvic

Management of congenital anomalies of the genitourinary tract, including epispadias and hypospadias

Microscopic surgery-epididymovasostomy, vasovasotomy

Open renal biopsy

Open stone surgery on kidney, ureter, bladder

Other plastic and reconstructive procedures on external genitalia

Penis repair for benign, or malignant disease including grafting

Percutaneous nephrolithotrispsy

Periurethal injections, e. g., collagen

Plastic and reconstructive procedures on ureter, bladder and urethra, genitalia, kidney

Reconstructive procedures on external male genitalia requiring prosthetic implants or foreign

Materials

Renal surgery through established nephrostomy or pyelostomy

Sphincter prosthesis

Surgery of testicle, scrotum, epididymis and vas deferents including biopsy, excision and reduction

Of testicular torsion, orchiopexy

Surgery upon adrenal gland

Surgery upon kidney, including total or partial Nephrectomy, incliding radical transthoracic approach

Surgery upon the penis

Surgery upon the ureter and renal pelvis

Surgery upon urinary bladder for benign or malignant disease including partial resection

Complete resection, diverticulectomy and reconstruction

Total simple cystectomy

Transurethral surgery, including resection of prostate and bladder tumors

Transurethral microwave thermotherapy ( TUMT ) for BPH

Transvesical ureterolithotomy

Treatment of urethral valves, open and endoscopic

Ureteral substitution

Uretero-calyceal anstomosis

Ureterocele repair, open endoscopic

Ureteroscopy including treatment of all benign and malignant processes

Urethral fistula repair, all forms including grafting

Urethral suspension procedures including grafting, all material types

Urethroscopy including treatment for all benign and malignant processes

Ventral/flank, herniorrhaphy as related to urologic operation

Visual urethrotomy

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

HISTORY AND PHYSICALS

Requested (Please initial) May perform history and physicals according to facility Medical staff Bylaws and Rules and Regulations

UROLOGY CORE PRIVILEGES

Requested (Please initial) Admit, evaluate , diagnose, treat (surgically or medically ) and provide consultation to patients of all ages, including critically ill patients in the intensive care unit in conformance with unit policy, except as specifically excluded from practice, presenting with medical and surgical disorders of the genitourinary system and the adrenal gland , and including endoscopic, percutaneous, and open surgery of congenital and acquired conditions of the urinary and reproductive system and their contiguous structures. 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 attached procedures list and such other procedures that are extensions of the same techniques and skills

UROLOGY LONG- TERM CARE CORE PRIVILEGES

Requested (Please initial) Admission and medical management of long- term care residents or geriatric patients with whom you have an ongoing medical relationship for continuity of care within the scope of requested and approved acute care privileges and within the approved standards of practice and scope of services provided by the long-term care unit

Requested (Please initial) Care of long-term care patients on a consultation basis. Consultation privileges shall be within the scope of privileges requested in the acute care setting and within the approved standards of practice and scope of care services provided by the long-term care unit.

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

SPECIAL NON-CORE PRIVILEGE CRITERIA

To be eligible to apply for the special non-core privileges listed below, the applicant must demonstrate successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of competence in performing the requested procedure consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. For Maintenance of Privileges, delivery of care or performance of procedures requiring equivalent knowledge and technical skills may be substituted for required experience with approval of the service chief.

Privileges failing outside the core set (special privileges) will require documentation of training, experience, and demonstration of sufficient participation in active practice to enable evaluation of competency: or documentation of successful completion of an approved continuing education course that provides both didactic and hands-on instruction in the procedure(s) requested

At reappointment and on an ongoing basis maintenance of clinic competence in special privileges may be evaluated through the medical staff peer review process, retrospective chard review, and/or direct observation on by the Department Chair or their designee.

USE OF LASER

Candela

Argon

YAG

KTP-532

Indigo 830

Holmium

Nd: YAG

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

LAPAROSCOPIC RADICAL PROSTATECTOMY (LRP)

LAPAROSCOPIC NEPHRECTOMY

RADIOACTIVE SEED IMPLATATION FOR PROSTATE CANCER

(IN COLLABORATION WITH RADIATION ONCOLOGY)

SACRAL NERVE STIMULATION FOR URINARY CONTROL

TRANSERUTHRAL MICROWAVE THERMOTHERAPY ( T U M T ) FOR BPH

PHOTO-SELECTIVE VAPORIZATION OF THE PROSTATE (PVP )

USE OF ROBOTIC ASSISTED (DA VINCI ) FOR UROLOGICAL PROCEDURES

(Prostatectomy Nephrectomy lymph node dissection, seminal visiculectomy, partial cystectomy, pyeloplasty, bladder verticulectomy, and other procedures as deemed appropriate by those specifically trained in these procedures)

SPECIAL NON-CORE PRIVILEGES (See Qualifications and/or Specific Criteria*)

To be eligible to apply for the special non-core privileges listed below, the applicant must demonstrate successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of competence in performing the requested procedure consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. For Maintenance of Privileges, delivery of care or performance of procedures requiring equivalent knowledge and technical skills may be substituted for required experience with approval of the service chief.

MODERATE SEDATION privileges

Please mark with initials)

Criteria: [Requires: Previous Experience and Maintenance of Privileges: must be able to demonstrate he/she has maintained competence by showing evidence of consultative or direct care of patients over the reappointment cycle privileges. In addition, the provider must complete a moderate sedation course and pass accompanying test.

Acknowledgement of Practitioner

I certify that I have not requested any privileges for which I am not eligible due to training, current experience and demonstrated performance. I agree to submit any requested documentation of such training or experience. I have read and agree to abide by, the Bylaws of Central Texas Veterans Health Care System.

I understand that in making this request I am bound by the Bylaws, Rules and Regulations and all Policies of the Medical Staff, Hospital, and Medical Service and hereby stipulate that I meet the threshold criteria. I further certify that I have had appropriate experience and/or training in diagnosing and managing these clinical entities. I am capable of caring for patients in age ranges expected to be part of the usual and customary training in my specialty.

Any restriction on the clinical scope of practice granted to me is waived in an emergency and in such a situation, my actions are governed by the applicable section of the medical staff bylaws or related documents.

Date:

Requestor

Recommend Approval/Approval with Modifications/Disapproval (Circle one):

Modifications/Reason for Disapproval:

Mark Couture, DPM

Associate Chief of Staff, Surgical Service

Olawale Fashina, MD, MHSA, CPE

Chief of Staff

Approve/Disapprove as Recommended (Circle one):

Michael L. Kiefer, MHA, FACHE

Executive Director

Form Approved for use by the Director effective

Valid FROM ___________________ TO ___________________

For Medical Staff Office Use Only image1.emf

Urology DRAFT 2022.doc

Central Texas Veterans Health Care System

SURGICAL SERVICE

Urology Core Clinical Privileges

To be eligible to apply for core privileges in Surgical Service, the applicant must meet the following qualifications unless otherwise grand fathered prior to July 1, 2008:

Background: the urology surgeon is an individual who specialize in treat surgical or medical management in the following areas: Medical and surgical disorders of the genitourinary system; the adrenal gland and including endoscopic, percutaneous, and open surgery of congenital and acquired conditions of the urinary and reproductive systems and the contiguous structures .surgical oncology (including coordinated multimodality management of the cancer patient by screening, surveillance, surgical adjunctive therapy, rehabilitation, and follow-up); management of trauma, including ischemic pain, gangrene, infections, and tumors. The responsibility for all phases of care of the injured patient is an essential component of general surgery; as well as complete care of critically ill patients with underlying surgical conditions in emergency departments and intensive care units.

Education: Must hold a doctor of medicine or doctor of osteopathy degree as described in VA Handbook 5005.

Minimum Formal Training: Successful completion of an approved residency in urology ACGME- or AOA-accredited post-graduate training program in Urology

Licensure: Must hold a current, valid, unrestricted license at all times.

Basic Life Support: Expected current certification as defined in station policy.

Certification: Current certification or active participation in the examination process leading to certification in the American Board of Urology or the American Osteopathic Board of Urology preferred but not required.

Required Previous Experience: Applicants for initial appointment may be requested to provide documentation of the number and types of hospital cases during the past 24 months. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, and other qualifications and for resolving any doubts.

Maintenance of Privilege: To be eligible to renew core privileges in Urology Surgery, the applicant must meet the following Maintenance of Privilege Criteria: Current demonstrated competence and an adequate volume of experience with acceptable results in the privileges requested for the past 24 months based on results of quality assessment/improvement activities and outcomes.

urology Core Privileges

(Please mark with initials)

Admit, evaluate, diagnose, and provide consultation and therapeutic treatments to inpatients and outpatients of all ages, except as specifically excluded from practice, with Privileges include admission, consultation, work-up, preoperative, operative, and postoperative care to correct or treat various conditions, illnesses, and injuries of the alimentary tract; abdomen and its contents; breasts, skin, and soft tissue; head and neck; vascular system (excluding the intracranial vessels, the heart, and those vessels intrinsic and immediately adjacent thereto); endocrine system; and extremity surgery (biopsy, I&D, varicose veins, foreign body removal, skin grafts, amputations).

Core General Surgery Privileges: Clinical privileges in the operative & perioperative care of diseases involving the alimentary tract; abdomen and its contents (including diaphragm); breast, skin, & soft tissue; head & neck; vascular system (excluding the intracranial vessels, the heart, & those vessels intrinsic & immediately adjacent thereto); endocrine system, basic laparoscopic procedures (i.e., laparoscopic appendectomy, laparoscopic cholecystectomy, & diagnostic laparoscopy); & minor extremity surgery (i.e., biopsy, I&D, varicose veins, foreign body removal, & skin grafts

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

Urology Core Procedure List:

All forms of prostate ablation

All forms of prostatectomy including biopsy

Anterior pelvic exenteration

Appendectomy as component of urologic procedure

Bladder instillation treatments for benign and malignant disease

Bowel resection as component of urologic procedure

Circumcision

Closure evisceration

Continent reservoirs

Creation of neo-bladders

Cystolithotomy

Cystoscopy

Enterostomy as component of urologic procedure

Excision of retroperitoneal cyst or tumor

Exploration of retroperitoneum

Extracorporeal shock wave lithotripsy

Hysterectomy, bilateral salpingoophorectomy in connection with cystectomy

Inguinal herniorrhaphy as related to urologic operation

Insertion/removal of ureteral stent

Intestinal conduit

Lararoscopic surgery, urologic for disease of urinary tract

Laparotomy for diagnostic or exploratory purposes (urologic related conditions)

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

Lymph node dissection-inguinal, retroperitoneal, or pelvic

Management of congenital anomalies of the genitourinary tract, including epispadias and hypospadias

Microscopic surgery-epididymovasostomy, vasovasotomy

Open renal biopsy

Open stone surgery on kidney, ureter, bladder

Other plastic and reconstructive procedures on external genitalia

Penis repair for benign, or malignant disease including grafting

Percutaneous nephrolithotrispsy

Periurethal injections, e. g., collagen

Plastic and reconstructive procedures on ureter, bladder and urethra, genitalia, kidney

Reconstructive procedures on external male genitalia requiring prosthetic implants or foreign

Materials

Renal surgery through established nephrostomy or pyelostomy

Sphincter prosthesis

Surgery of testicle, scrotum, epididymis and vas deferents including biopsy, excision and reduction

Of testicular torsion, orchiopexy

Surgery upon adrenal gland

Surgery upon kidney, including total or partial Nephrectomy, incliding radical transthoracic approach

Surgery upon the penis

Surgery upon the ureter and renal pelvis

Surgery upon urinary bladder for benign or malignant disease including partial resection

Complete resection, diverticulectomy and reconstruction

Total simple cystectomy

Transurethral surgery, including resection of prostate and bladder tumors

Transurethral microwave thermotherapy ( TUMT ) for BPH

Transvesical ureterolithotomy

Treatment of urethral valves, open and endoscopic

Ureteral substitution

Uretero-calyceal anstomosis

Ureterocele repair, open endoscopic

Ureteroscopy including treatment of all benign and malignant processes

Urethral fistula repair, all forms including grafting

Urethral suspension procedures including grafting, all material types

Urethroscopy including treatment for all benign and malignant processes

Ventral/flank, herniorrhaphy as related to urologic operation

Visual urethrotomy

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

HISTORY AND PHYSICALS

Requested (Please initial) May perform history and physicals according to facility Medical staff Bylaws and Rules and Regulations

UROLOGY CORE PRIVILEGES

Requested (Please initial) Admit, evaluate , diagnose, treat (surgically or medically ) and provide consultation to patients of all ages, including critically ill patients in the intensive care unit in conformance with unit policy, except as specifically excluded from practice, presenting with medical and surgical disorders of the genitourinary system and the adrenal gland , and including endoscopic, percutaneous, and open surgery of congenital and acquired conditions of the urinary and reproductive system and their contiguous structures. 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 attached procedures list and such other procedures that are extensions of the same techniques and skills

UROLOGY LONG- TERM CARE CORE PRIVILEGES

Requested (Please initial) Admission and medical management of long- term care residents or geriatric patients with whom you have an ongoing medical relationship for continuity of care within the scope of requested and approved acute care privileges and within the approved standards of practice and scope of services provided by the long-term care unit

Requested (Please initial) Care of long-term care patients on a consultation basis. Consultation privileges shall be within the scope of privileges requested in the acute care setting and within the approved standards of practice and scope of care services provided by the long-term care unit.

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

SPECIAL NON-CORE PRIVILEGE CRITERIA

To be eligible to apply for the special non-core privileges listed below, the applicant must demonstrate successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of competence in performing the requested procedure consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. For Maintenance of Privileges, delivery of care or performance of procedures requiring equivalent knowledge and technical skills may be substituted for required experience with approval of the service chief.

Privileges failing outside the core set (special privileges) will require documentation of training, experience, and demonstration of sufficient participation in active practice to enable evaluation of competency: or documentation of successful completion of an approved continuing education course that provides both didactic and hands-on instruction in the procedure(s) requested

At reappointment and on an ongoing basis maintenance of clinic competence in special privileges may be evaluated through the medical staff peer review process, retrospective chard review, and/or direct observation on by the Department Chair or their designee.

USE OF LASER

Candela

Argon

YAG

KTP-532

Indigo 830

Holmium

Nd: YAG

Requestor’s Initials

Service Chief’s Initials (Required in boxes below and applicable box to the right)

RECOMMEND APPROVAL

RECOMMEND APPROVAL WITH

RECOMMEND

LAPAROSCOPIC RADICAL PROSTATECTOMY (LRP)

LAPAROSCOPIC NEPHRECTOMY

RADIOACTIVE SEED IMPLATATION FOR PROSTATE CANCER

(IN COLLABORATION WITH RADIATION ONCOLOGY)

SACRAL NERVE STIMULATION FOR URINARY CONTROL

TRANSERUTHRAL MICROWAVE THERMOTHERAPY ( T U M T ) FOR BPH

PHOTO-SELECTIVE VAPORIZATION OF THE PROSTATE (PVP )

USE OF ROBOTIC ASSISTED (DA VINCI ) FOR UROLOGICAL PROCEDURES

(Prostatectomy Nephrectomy lymph node dissection, seminal visiculectomy, partial cystectomy, pyeloplasty, bladder verticulectomy, and other procedures as deemed appropriate by those specifically trained in these procedures)

SPECIAL NON-CORE PRIVILEGES (See Qualifications and/or Specific Criteria*)

To be eligible to apply for the special non-core privileges listed below, the applicant must demonstrate successful completion of an approved, recognized course when such exists, or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of competence in performing the requested procedure consistent with criteria set forth in medical staff policies governing the exercise of specific privileges. For Maintenance of Privileges, delivery of care or performance of procedures requiring equivalent knowledge and technical skills may be substituted for required experience with approval of the service chief.

MODERATE SEDATION privileges

Please mark with initials)

Criteria: [Requires: Previous Experience and Maintenance of Privileges: must be able to demonstrate he/she has maintained competence by showing evidence of consultative or direct care of patients over the reappointment cycle privileges. In addition, the provider must complete a moderate sedation course and pass accompanying test.

Acknowledgement of Practitioner

I certify that I have not requested any privileges for which I am not eligible due to training, current experience and demonstrated performance. I agree to submit any requested documentation of such training or experience. I have read and agree to abide by, the Bylaws of Central Texas Veterans Health Care System.

I understand that in making this request I am bound by the Bylaws, Rules and Regulations and all Policies of the Medical Staff, Hospital, and Medical Service and hereby stipulate that I meet the threshold criteria. I further certify that I have had appropriate experience and/or training in diagnosing and managing these clinical entities. I am capable of caring for patients in age ranges expected to be part of the usual and customary training in my specialty.

Any restriction on the clinical scope of practice granted to me is waived in an emergency and in such a situation, my actions are governed by the applicable section of the medical staff bylaws or related documents.

Requestor

Mark Couture, DPM

Associate Chief of Staff, Surgical Service

Olawale Fashina, MD, MHSA, CPE

Chief of Staff

Approve/Disapprove as Recommended (Circle one):

Michael L. Kiefer, MHA, FACHE

Executive Director

Form Approved for use by the Director effective

Valid FROM ___________________ TO ___________________

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