KALEIDA HEALTH
Name ____________________________________
Date ____________________
DELINEATION OF PRIVILEGES –
THORACIC/CARDIOVASCULAR SURGERY
GENERAL STATEMENTS
Procedures are separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education and
experience. Level II procedures may or may not require evidence of additional training beyond residency. Documentation of
additional training and/or experience is required for all Level III procedures.
Title 10 of the Official Code of Rules and Regulations of the State of New York section 405.29(d)(3)(i)(a) requires cardiac
surgeons perform a minimum of 50 cardiac surgeries a year, with formal review for physicians with annual volumes below
minimum volume standards.
Procedures designated with an asterisk (*) indicate that Moderate (Conscious) Sedation may be required. If you do not have
Moderate (Conscious) Sedation privileges, you must invite a Kaleida Health anesthesiologist to participate in the procedure.
Procedures designated with a cross (+) are presently granted solely to physicians that are part of an exclusive contract with Kaleida
Health. If you are not part of the contract, your request for these privileges will not be granted.
Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency program in that core
specialty. The removal or restriction of these privileges would require further investigation as to the individual’s overall ability to
practice, but there is no need to delineate these privileges individually.
LEVEL I (CORE) PRIVILEGES
( > 18 years of age) Those procedures which are assumed to have been mastered following satisfactory completion of an approved
cardiothoracic surgical training program, and documentation of current competency.
Admission and Follow-Up
Trachea (open tracheostomy, biopsies, repair)
Lung (plication, resection, incision, biopsy)
Chest Wall, Pleura, Mediastinum (endoscopy, repair, resect, biopsy)
Diaphragm (excision, repair)
*Pacemakers (insertion, revision, replacement)
Esophagus (incision, endoscopy, excision, bypass, repair)
Incision and Drainage of Pericardium (Pericardial Window)
*AICD (Automatic Implantable Cardiac Defibrillators) (insertion, revision, replacement, laser)
Access to Spine
Thoracic Cardiovascular Surgery
Name:________________________________________________
Page 2
PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will
return applications that ignore this directive.
LEVEL II PRIVILEGES - ( > 18 years of age) Those
procedures listed below, including those not listed in Level I,
which may require documentation of additional experience or
training.
PHYSICIAN
REQUEST
Granted
Not
Granted*
Granted
Not
Granted*
With Following
Requirements**
(Provide Details)
NOTE: Procedures designated with a cross (+) are presently
granted solely to physicians that are part of an exclusive contract
with Kaleida Health. If you are not part of the contract, your
request for these privileges will not be granted.
+ Coronary Arteries (CABG and other revascularization, onpump)
+ Heart Valves & Septa (closed valvotomy, open plasty,
replacements)
+ Heart Muscle (papillary muscle, chordae, annuloplasty)
+ Septal Defect (creation and repair)
+ Congenital Heart Defects (ASD, VSD) (graft repair of septal
defects) (septal repair, NEC)
+ Thoracic Aorta (endarterectomy) (resection) (replacement)
+ Biventricular Pacing
+ Other Heart (incision heart and pericardium) (biopsy, excision)
Emergent cardiac procedures for treatment of perforation,
hemorrhage or tamponade.
Tracheal Reconstruction
Endoscopic Destruction Bronchial Lesion (via Laser)
Extracorporeal Membrane Oxygenation (ECMO)
LEVEL III PRIVILEGES - Those procedures which
categorically require documentation of additional training or
significant experience, such as high risk procedures or new
procedures. Volume criteria (in parenthesis) may be applicable.
NOTE: Procedures designated with a cross (+) are presently
granted solely to physicians that are part of an exclusive contract
with Kaleida Health. If you are not part of the contract, your
request for these privileges will not be granted.
+ Arrhythmia Surgery
+ Endovascular Stent in Thoracic Aorta
+ Percutaneous Thoracic Aortic Stent Placement
+ Implantable/Explantation Cardiac Ventricular Assist Devices
+ Coronary Bypass off Pump (Requires satisfactory performance
of fifty (50) cases proctored by a surgeon currently credentialed to
perform these procedures.)
+ Cardiac Mapping (Requires satisfactory performance of
twenty-five (25) procedures proctored by a surgeon currently
credentialed to perform this procedure.)
+ Transmyocardial Laser Revascularization (TMR)
PHYSICIAN
REQUEST
With Following
Requirements**
(Provide Details)
Thoracic Cardiovascular Surgery
Name:________________________________________________
LEVEL III PRIVILEGES (cont’d) - Those procedures
which categorically require documentation of additional training
or significant experience, such as high risk procedures or new
procedures. Volume criteria (in parenthesis) may be applicable.
NOTE: Procedures designated with a cross (+) are presently
granted solely to physicians that are part of an exclusive contract
with Kaleida Health. If you are not part of the contract, your
request for these privileges will not be granted.
+ Lead Extractions by Laser (Completion of an ACGME-approved
Cardiac Electrophysiology Fellowship documenting the
performance of a minimum of 5 cases OR if training completed
prior to the offering of a Cardiac Electrophysiology fellowship,
provide documentation of extensive experience in the performance
of Lead Extractions, to include the performance of 5 Lead
Extractions per year for the immediate past 2 years.)
Documentation of at least one (1) lead extraction during the
previous two years is required at reappointment.
Lung Transplant, Heart Transplantation
(Applicants must have satisfactorily completed a fellowship in
heart and lung transplantation. Cases must be done under the
direct supervision of the Director of Heart/Lung Transplantation.)
Percutaneous Tracheostomy (Requires satisfactory performance of
five (5) procedures proctored by a surgeon currently credentialed
to perform this procedure.)
Thorascopy (Applicant must document experience as surgeon in
at least ten (10) procedures)
Pediatric Cardiac Surgery (</= 18 yrs. old)
(Requires one year fellowship in pediatric cardiac surgery, and
approval by the Director of Pediatric Cardiac Surgery.)
Pediatric Extracorporeal Membrane Oxygenation (ECMO)
Conscious Sedation
1. Initial Request: Must have completed a Kaleida Health
approved training course (documentation required) or training
during ACGME Accredited Residency (verification letter from
program director required.)
2. Maintenance of privilege: The course needs to be taken again
every 4 years.
3. The course can be found at:
www.kaleidahealth.org/physicians/ModerateSedation/
PHYSICIAN
REQUEST
Granted
Not
Granted*
Page 3
With Following
Requirements**
(Provide Details)
Thoracic Cardiovascular Surgery
Name:________________________________________________
KEY
**WITH FOLLOWING REQUIREMENTS
*NOT GRANTED DUE TO:
Provide Details Below
Provide Details Below
1) Lack of Documentation
2) Lack of Required Training/Experience
3) Lack of Current Competence (Databank Reportable)
4) Other (Please Define) (i.e., Exclusive Contract)
Page 4
1)
2)
3)
4)
With Consultation
With Assistance
With Proctoring
Other
(Please Define)
DETAILS:_________________________________________________________________________________________________
__________________________________________________________________________________________________________
National Practitioner Databank Disclaimer Statement:
Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for
reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986
(43 U.S.C. 11101 et seq.)
______________________________/_______
Signature of Applicant
Date
That I, the Chief of Service, have consulted with the Chief of the Division of Pediatric Surgical Services (or designee)
concerning any requests of this applicant for Level III privileges on patients below the age of 18.
_________________________________/________
Signature of Chief of Service
Date
APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS
(CTSU/mso-Reviewed & Revised-11-2015)