VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
INSTRUCTIONS
1. Advanced Procedure Privileges: Approved procedural privileges requiring additional education and training and may be granted only upon evidence of
initial and ongoing competency.
2. Form Requirement: Professional Staff Privileged providers requesting advanced procedure privileges must do so using this form. Requests with
supporting documentation are submitted to Provider Support Services and thereafter reviewed by the Joint Practice Committee.
• Colposcopy, Moderate Sedation, Circumcision, and Nitrous Oxide Administration privileges require a separate application available through
Provider Support Services.
3. Supporting Documentation: Requests for advanced procedure privileges at initial appointment, reappointment and additional privilege additions must
be supported by the following:
a. Log of procedures performed indicating MR #, date, proceduralist, preceptor, and name of procedure; and/or *simulation/animal lab certificate
of completion as appropriate.
b. Current procedural protocols are accessible from the practitioner’s worksite and on file with the Office of Advanced Practice.
c. Required forms must be signed by supervising physician.
4. Supervision: Initial procedures must be proctored by a privileged provider, under direct, personal instruction and supervision. Once required initial
procedures have been completed and competency verified and documented by proctor, the practitioner may perform the procedures under direct
supervision with a privileged provider on-site and immediately available. Supervision would continue until privileges are approved through the
privileging process.
5. Scope: Advanced procedures will only be approved if medically necessary as an integral part of the provider’s scope of practice.
6. Competency**: The initial and continued competency requirements are subject to validation and attestation of competency and requirements may be
increased based on national standards or at the supervising physician’s discretion.
7. FPPE/OPPE: All providers privileged to perform advanced procedures are subject to the mandates of focused professional practice evaluation (FPPE) and
ongoing professional practice evaluation (OPPE).
8. If a procedure is not listed on this form, please refer to the “Application for Adding Advanced Procedures to the Advanced Procedure Privileges Form”.
Formal review and approval of this application by the Joint Practice Committee is necessary before a provider may be privileged to perform the
procedure.
*Simulation is a technique used to replace or amplify real experience in an interactive manner. Simulation training must include a summative assessment which includes a return demonstration. A Competency
Certificate must be awarded to the Advanced Practice Provider upon completion of an approved simulation training. Standards of Competency will be determined by the AP Leader and supervising physicians.
Off-site simulation training for procedural competency must be subject to approval by the Advanced Practice Leader and supervising physicians. Qual Saf Health Care. Oct 2004; 13 (Suppl 1): i2–i10. doi:
10.1136/qshc.2004.009878 Harvey, L., 2004–14, Analytic Quality Glossary, Quality Research International, http://www.qualityresearchinternational.com/glossary/
**APSC Position Statement on Simulation for Competency Requirements: The Advanced Practice Standards Committee accepts simulation as a way to meet competency in procedural requirements for
Advanced Practice Professionals (APP). Simulation may be used when there are insufficient opportunities to meet competency requirements within a patient population. Appropriateness of simulation for
demonstration of procedural competency is at the discretion of APP Leader in collaboration with the supervising physician. Competency is defined as the acquisition of knowledge skills and abilities at a level
of expertise sufficient to accurately perform the procedure.
1
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
Practitioner Name:
Department: ______________________________________________________
__________________________
Primary Supervising Physician: ____________________________________________________________________________________________________________________
The initial and continued competency requirements are subject to validation and attestation of competency and requirements may be increased
based on national standards or at the supervising physician’s discretion.
Advanced Procedures
Initial
Adding
Reappointment
FOR REFERENCE ONLY:
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
MARK THE PRIVILEGE TO
competency thresholds and approval to
REQUEST
perform
1
2
3
4
5
6
7
8
9
10
PEDIATRIC
NEONATAL
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
PRIVILEGE
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENT PERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
ADULT
n/a
Acupuncture for detoxification (requires certification)
Appendicostomy & cecostomy tube & management
Arterial line, insertion
Arterial sheath, removal
Arteriotomy closures- femoral
Arthrocentesis
Biopsy: Bone marrow biopsy / aspiration
Biopsy: Cervical biopsy
Biopsy: Endometrial biopsy
Biopsy: FNA/core/percutaneous needle biopsy
2
3
3
3
4
5
4
5
5
5
10
4
2
2
3
4
3
4
4
4
5
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval to
MARK THE PRIVILEGE TO
perform
PRIVILEGE
REQUEST
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15
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25
26
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31
32
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PEDIATRIC
NEONATAL
n/a
n/a
n/a
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n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ADULT
n/a
Biopsy: Prostate biopsy
Biopsy: Shave biopsy
Biopsy: Skin biopsy
Biopsy: Skin punch biopsy
Bone markers, insertion
Bone markers, placement
Bone marrow harvest/assist
Botox injections
Bowel irrigation
Bronchoscopy for lavage
Cantherone treatments for mulluscum blistering agent
Cardiac ventricular assist device optimization
Central venous line, insertion
Cervical collar management and removal – PEDIATRIC
Cervical Immobilization
Chemical or talc pleurodesis, bedside
Chemical peel – dermatology
Chest tube, insertion (for fluid or air)
Chest tube, removal
*Circumcision (*requires separate application available from PSS)
Closed/open/percutaneous surgical drain: management & removal
Complex laceration repair
Complex wound management
*Colposcopy (*requires separate application available from PSS)
3
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENTPERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
5
3
3
3
4
5
4
3
3
5
3
4
3
3
4
4
3
3
3
--3
4
3
---
4
2
2
2
3
4
2
2
2
4
2
3
2
2
3
3
2
2
2
Separate application
2
3
2
Separate application
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval to
perform
MARK THE PRIVILEGE TO
PRIVILEGE
REQUEST
PEDIATRIC
35
36
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42
43
44
45
46
47
48
49
50
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52
53
54
55
n/a
n/a
NEONATAL
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ADULT
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Cryosurgery skin lesions
CSF draw from EVD, lumbar drains, externalized shunts
Cystoscopy, stent removal, urethral dilation,
Electrodessication and curettage – superficial skin cancers
Electromyography (EMG) uroflow
Endotracheal intubation - NEONATAL
Endotracheal Intubation – PEDIATRIC/ADULT
Epicardial pacing wire removal - PEDIATRIC
Epicardial pacing wires, removal
Epistaxis control - PEDIATRIC
Escharotomy
Excision of toenail or fingernail with digital blocking - PEDIATRIC
Facet and joint injections/aspiration
Facet and other joint injections/aspirations - PEDIATRIC
Facet and joint injections/aspiration - image guided joint
injections (Interventional radiology)
Femoral arterial sheath insertion
Filler injections (Dermatology)
Fracture closed reduction (casting/splinting/traction)
Fracture/dislocation immobilization
Gastrostomy tube, exchange and removal
Hemorrhoid banding
4
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENTPERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
3
4
5
3
3
3
5
5
4
4
3
4
3
4
2
3
4
2
2
3
3
4
3
3
3
3
2
3
5
4
5
3
4
4
4
4
4
2
3
3
3
3
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval to
perform
MARK THE PRIVILEGE TO
PRIVILEGE
REQUEST
PEDIATRIC
NEONATAL
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ADULT
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Incision and drainage of minor abscess (perirectal, breast, axillary,
extremity, skin, etc.)
Incision and drainage of superficial abscess, paronychia and/or
sebaceous cyst - PEDIATRIC
Incision and drainage thrombosed hemorrhoids
Injection bulking agents; botox (urology)
Instillation of antibiotics/tissue plasminogen activator (tPA) into
external ventricular drain (EVD)
Intense pulse light (IPL) removal benign lesions, photo-damaged skin
Intraaortic balloon pump, removal
Intracranial pressure (ICP) monitor placement
Intranasal sphenopalatine ganglion block
Intrathecal baclofen trial - PEDIATRIC
Intrathecal baclofen trial
Intrathecal pump myelogram - PEDIATRIC
Intrathecal pump myelogram
Intrathecal pump myelogram refill - PEDIATRIC
Intrathecal pump myelogram refill
Intrathecal pump reprogram - PEDIATRIC
Intrathecal pump reprogram
Joint aspirations – PEDIATRIC
Joint injections/aspiration
Joint injection - Trochanteric hip injections
Lap band adjustment
5
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENT PERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
5
4
4
3
5
5
4
3
5
4
3
5
5
5
5
5
5
5
5
5
5
5
4
3
3
3
2
4
4
4
4
3
4
3
4
3
4
3
3
2
2
2
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval to
perform
MARK THE PRIVILEGE TO
PRIVILEGE
REQUEST
PEDIATRIC
NEONATAL
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
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n/a
n/a
n/a
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n/a
n/a
n/a
n/a
n/a
n/a
ADULT
n/a
Laser hair removal
Laser treatment, leg veins
Lumbar puncture
Lumbar puncture with drain insertion
Lysis labial adhesions
*Moderate sedation (*requires separate application available from
PSS)
Needle decompression
Needle localization
Neurostimulator – analyze/program
*Nitrous Oxide (*requires separate application available from PSS)
Occipital nerve block
Ommaya reservoir - access
Oropharyngeal soft tissue biopsies
Paracentesis
Percutaneous drain insertion - superficial
Photodynamic therapy-dermatology
Placement of luteinizing hormone releasing hormone (LHRH) agonists
(urology)
Placement of negative pressure dressing
Pulmonary artery catheter, insertion
6
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENT PERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
3
3
3
5
3
2
2
3
4
2
---
Separate application
3
10
10
--3
3
5
5
5
3
3
5
5
Separate application
3
2
4
5
5
2
3
2
4
5
3
5
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval
to perform
MARK THE PRIVILEGE TO
PRIVILEGE
REQUEST
PEDIATRIC
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
NEONATAL
ADULT
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENT PERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
Reduction of dislocations
Reduction of finger and toe dislocations
Reduction of nursemaid elbow– PEDIATRIC
Removal of double J stent
Screening ultrasound: scrotal, prostate, renal
Shunt reprogramming
Shunt reprogramming - PEDIATRIC
Shunt tap - ADULT
Shunt tap - PEDIATRIC
Shuntograms - ADULT
Shuntograms - PEDIATRIC
Slit lamp examination with or without foreign body removal
Small-vein sclerotherapy (dermatology)
Splinting of sprains
Suturing – simple/ minor lacerations -PEDIATRIC
Suturing – simple/minor lacerations
Trichloracetic acid (TCA) application – anal condyloma
Thoracentesis
Thrombin injection for pseudoaneursym
Tonometry
4
4
3
5
10
3
4
3
4
3
4
5
3
4
5
3
3
5
5
3
3
3
2
4
5
2
3
2
3
2
3
4
2
3
4
2
2
4
4
2
Tracheostomy decannulation - PEDIATRIC
5
4
7
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
MARK THE PRIVILEGE TO
REQUEST
SCOPE OF PRACTICE GUIDE: Use as
reference when selecting for
competency thresholds and approval
to perform
PEDIATRIC
NEONATAL
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
ADULT
n/a
n/a
n/a
n/a
n/a
n/a
n/a
PRIVILEGE
n/a
Tracheostomy, decannulation
Tracheostomy downsize/exchange/upsize
Transthoracic catheter removal
Trephination of subungual hematoma
Trigger point injections
Tunneled catheter insertion
Tunneled catheter removal/repair
Tunneled catheter with reservoir removal
Umbilical arterial catheter, insertion
Umbilical venous catheter, insertion
Vasectomy
Video urodynamics - PEDIATRIC
Video urodynamics
8
CONTINUED
INITIAL
COMPETENCY
COMPETENCY
(DOCUMENTED OVER AN
(TO BE
APPOINTMENT PERIOD
OBTAINED
AND RESULTS REVIEWED
UNDER
BY SUPERVISING
SUPERVISION)
PHYSICIAN)
4
4
5
4
3
5
4
4
3
3
10
3
5
3
3
4
3
3
4
3
3
3
3
5
2
2
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016
VANDERBILT UNIVERSITY MEDICAL CENTER
APPLICATION FOR
ADVANCED PROCEDURE PRIVILEGES
ADVANCED PROFESSIONAL STAFF WITH PRIVILEGES (PSP)
Initial Appointment Proctor Approval: I have instructed, observed, or supervised throughout the required number of procedures for the provider listed below
who is requesting advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on
established practice protocols, unless otherwise noted.
Reappointment Proctor Approval: I have reviewed the procedural notes and technique for procedures for the provider listed below who is requesting continued
advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on established
practice protocols, unless otherwise noted.
Proctor/Preceptor (Privileged APRN/PA/MD) Signature: ______________________________________________
Proctor printed Name: __________________________________________________________________________
Date: _____________________
Requesting Practitioner Signature: ________________________________________________________________
Practitioner printed Name: ______________________________________________________________________
Date: _____________________
Department Approvals:
Supervising Physician: __________________________________________________________________________
Supervising Physician printed Name: ______________________________________________________________
Date: _____________________
Department Chair/Chief of Staff: _________________________________________________________________
Department Chair/Chief of Staff printed Name: _____________________________________________________
Date: _____________________
9
Revised September 4, 2015
Revised August 11, 2015
Revised January 6, 2016