Neurophysiology Monitoring B Credentialing.doc

Delineation of Clinical Privileges

DEPARTMENT OF VETERANS AFFAIRS

SOUTHERN ARIZONA VA HEALTH CARE SYSTEM

TUCSON AZ

SURGICAL CARE LINE – NEUROPHYSIOLOGY MONITORING

, MD

I request clinical privileges to perform Intraoperative Neuromonitoring in the Operating Room setting. Neurophysiological modalities include e.g. electroencephalography (EEG), sensory and motor evoked potentials, electromyography (EMG), electrophysiological mapping, and transcranial and microvascular (Doppler) to assess the function of the nervous system during surgical intervention.

I understand that activities or procedures not specifically listed which are usually considered to be within the purview of the CL or Section to which I will be assigned will be automatically extended. However, any such procedure requiring the use of the operating rooms is subject to prior review by the Chief of the Surgical Care Line.

If you are a certified DEA-X/DATA Waived prescriber, you may treat patients within the bounds of your individual authorization from the Center for Substance Abuse Treatment (CSAT).

I agree to comply with the Bylaws and Rules and Regulations of the Southern Arizona VA Health Care System, to maintain and promptly complete adequate medical records, and to permit evaluation of my performance by peer review.

TO BE COMPLETED BY APPLICANT (INITIALS)

TO BE COMPLETED BY

CARE LINE CHIEF

Approval

(CL Chief’s) Disapproval

(CL Chief’s) Settings

Signature of Applicant

Date

VA Concurrence/Approval Signatures/Dates (not valid until signed by the Director):

I have reviewed the applicant's request for clinical privileges. Based on the information provided, training and/or experience, board certification or completion of the formal educational requirements for board certification, it is recommended that privileges be granted as delineated above.

CHIEF, SURGICAL CARE LINE

DATE

Medical Executive Board Review: _____________

Recommend Approval:

Approved

CHAIRMAN, MEDICAL EXECUTIVE BOARD

DIRECTOR

Effective Date: ____________________

LEGEND

1 - OR - OPERATING ROOM

2 - PROCEDURE/CONS SED AREA – E.G. CATH LAB, GI/GU, RADIOLOGY, Pre/Post UNIT

3 - EMERGENCY DEPARTMENT

4 - ICU - MICU, SICU, SDU

5 - INPATIENT: 2S, 3N, 3E, 1W

6 - CLINIC–ANY OUTPATIENT AREA

7 - RTC – BLDG 60

8 - SWBRC – BLDG 30

9 - HOME CARE

10 - TELEMEDICINE

CRITERIA FOR PRIVILEGING NEUROPHYSIOLOGY MONITORING

Initial Category I Privileges

1. Meet the criteria for privileging in Neurology, Neurosurgery or Physical Medicine & Rehabilitation

2. Meet one or more of the following certifications:

a. Certification in the subspecialty of Clinical Neurophysiology

OR

b. Certification with special competency in Intraoperative Neuromonitoring

OR

c. Diplomat certification in Neurophysiology concentrating on EMG and Evoked Potentials.

OR

d. An applicant who is not applying directly out of a residency or fellowship shall provide a quality profile from hospital(s) where he/she currently has privileges showing his or her clinical activity Neurophysiology Monitoring privileges for the past 12 months. This would be in addition to peer reference(s) that speak to the provider’s current clinical competency in Neurophysiology monitoring.

3.

Observation Requirement: After initial appointment and with 90 days, at least 5 cases will be observed or monitored by a staff member. The initial monitoring period will also include an evaluation of competency. A written report of these observations must be submitted to the Medical Executive Board.

Biennial renewal of privileges

1. On-going Professional Practice Evaluation (OPPE) will be utilized as an evaluation in addition to primary source verification of other sources to support current clinical competency of privileges. 100 percent review.

2. Completion of 40 hours of continuing medical education during the preceding 2 years.

Procedures per year):

Intra-operative Neurophysiological Monitoring of Evoked Potentials for Telemedicine - 5 per year Criteria to Add a New Delineated Privilege

Letter from supervisor, chief, or program director at another hospital/fellowship/residency who can attest to current clinical competency of the privileges requested. Documentation to include number of procedures performed and outcomes of these cases.

Approved by MEB: 25 Nov 2019