ANESTHESIOLOGY/PAIN MANAGEMENT
DELINEATION OF PRIVILEGES
DEPARTMENT OF SURGERY
Name: _____________________________________________________________________Date: __________
PRIVILEGE CRITERIA
To be eligible to use this form to request clinical privileges, general membership criteria as indicated in the medical staff
bylaws, must be met in addition to the following minimum threshold criteria for privileges.
Basic Education
Minimal Formal
Training
Board Certification
Required Experience
Current Competence
FPPE
Reappointment
CME
NOTE
MD or DO
Minimum formal training: Successful completion of an ACGME or AOA accredited training
program in the specialty where privileges are sought
Applicants shall be board certified, board qualified as defined by the specialty board for
his/her specialty, or comparably qualified as defined by the Medical Executive Committee
Applicants for initial appointment will be requested to provide documentation of at least
250 anesthesia 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.
A Focused Professional Practice Evaluation (FPPE) will be conducted on each new
privilege according to guidelines.
Current demonstrated competence and an adequate volume through a case log
according to criteria outlined in the privilege delineation, with acceptable outcomes for
the past 24 months based on results of the focused professional practice evaluation
process (FPPE), and the ongoing focused professional practice evaluation (OPPE) process.
Evidence of current ability to perform privileges requested is required of all applicants for
renewal of privileges
The applicant shall provide documentation of continuing education as related to the
clinical privileges requested.
The ability to ‘Admit’ patients is determined by the selection of Staff Status as defined by the
Medical Staff Bylaws.
Please do not write in privileges
If you wish to add a privilege that is not listed on this form, please contact Medical Staff Services.
In case of emergency, all practitioners with privileges are expected to do whatever he/she can within the scope of
their License to save a patient according to the medical staff bylaws provision entitled “Emergency Privileges”.


Management of patients rendered unconscious or insensible to pain and emotional stress during
surgical and certain other medical procedures, including pre-, intra-, and postoperative evaluation and
treatment; the support of life functions and vital organs under the stress of anesthetic, surgical, and
other medical procedures; management of patients with a difficult airway; ventilator management
<24 hours in post-op patients; management of problems in pain relief; cardiopulmonary resuscitation;
and supervision of patients in post-anesthesia care units and critically ill patients in special care units;
except for those listed under Special Privileges.
Premature and age <6 months

Adolescents 14 to 18 years
Children 6 months to 14 years

Adults 18 years and greater
Not
Recommended
State Reason
Recommend
ANESTHESIA CORE - PLEASE CROSS THROUGH THOSE YOU DO NOT WISH TO
REQUEST:
Criteria Met
REQUESTED
(Check here)
Chair Review ONLY
Procedure
Criteria
COMPREHENSIVE CRITICAL CARE
Requires certificate of subspecialty certification on Critical Care
Medicine Anesthesiology (CCM-A), eligibility for CCM-A, or
documentation of equivalent credentials:
State Reason
Not
Recommended
Recommend
SPECIAL PRIVILEGES
To be eligible to apply for a special procedure privilege listed below the applicant must
demonstrate successful completion of an approved and recognized course or acceptable
supervised training in residency, fellowship, or other acceptable experience; and provide
documentation of competence in performing that procedure as listed below.
Criteria Met
REQUESTED
(Check here)
Anesthesia/Pain Management – DELINEATION OF PRIVILEGES
Comprehensive management of patients in critical care units
including but not limited to the use of procedures such as chest
tube insertion, transvenous pacemaker insertion, cardioversion,
hemodialysis catheter insertion, ultrafiltration, thoracentesis,
and pericardiocentesis.
Requires qualifications for general anesthesiology, plus
documentation of current training and/or experience in the
management of critically ill patients:
LIMITED CRITICAL CARE
This category is limited to use of the following procedures:
fiberoptic laryngotracheobronchoscopy, mechanical ventilation,
and invasive hemodynamic monitoring.
Requires certificate of subspecialty certification for pain
management (PM), eligibility for participation in the
examination process for PM, or documentation of equivalent
credentials:
COMPREHENSIVE PAIN
MANAGEMENT
LIMITED PAIN MANAGEMENT
Comprehensive management of acute and chronic pain;
continuous intraspinal narcotics, neurolytic nerve blocks, facet
blocks, and dorsal column stimulator.
Does not require subspecialty certification for pain management
This category is limited to use of the following procedures:
Epidural steroids, post-op pain blocks (including spinal and
epidural); femoral, interscalene, sciatic catheters for short term
pain management; epidural blood path; trigger point injections;
acupuncture
ACKNOWLEDGMENT OF PRACTITIONER
I have requested only those privileges for which, by education, experience and/or licensure/certification, I am qualified to
perform, and that I wish to exercise at Texas General Hospital. I also acknowledge that my professional malpractice insurance
extends to all privileges I have requested.
I understand that in exercising any privileges granted, I am constrained by hospital and medical staff policies and rules
applicable generally and any applicable to the particular situation.
Signature of Applicant:
Date:
DEPARTMENT/COMMITTEE CHAIR SIGNATURE
Comments/Notes: _______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Signature:
Approved – CC: 11/12
Date:
MEC: 11/12
BOD: 11/12
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