1. RENOWN REGIONAL MEDICAL CENTER
DELINEATION of PRIVILEGES
DEPARTMENT OF RADIOLOGY
BASIC EDUCATION: M.D. or D.O.
MINIMAL FORMAL TRAINING: Successful completion of an ACGME or AOA- approved residency-training program in
diagnostic radiology. The applicant must be board eligible or certified by the American Board of Radiology.
REQUIRED PREVIOUS EXPERIENCE: For individuals who have just completed an approved residency, a letter from their
program chairman, supporting the granting of the privileges requested is necessary. For all others, the successful applicant must
have been actively engaged in the practice of radiology for not less than 18 months in the last two years, and references are required
from the chair of radiology from the hospital that the applicant was most recently affiliated or from two radiologists. The Director of
the Department of Radiology will recommend the granting of full privileges if the documented experience is broad enough. He/she
may recommend further documentation of clinical competence or additional mentoring in a specific area before granting privileges
in that area.
Those applicants who are not board certified at the time of application but who have completed their residency or fellowship training
within the last five years shall be eligible for Medical Staff appointment. However, in order to remain eligible, those applicants must
achieve board certification in their primary area of practice within five (5) years from the date of completion of their residency or
____ Core Privileges in Radiology (CR.RD)
Reflecting the position of the American Board of Radiology, the education and training for the practice of radiology includes
extensive study in the physics of radiant energy, radiation protection and the application of ionizing radiation to the
morphology and pathophysiology of disease. The physician should have a thorough understanding of the indications for an
imaging or percutaneous image guided procedure, as well as the ability to recognize and respond to complications from
either. Physicians should be familiar with alternative and complementary imaging and interventional procedures and
should be capable of correlating the results of these procedures. The physician should be competent to supervise or perform
the above-mentioned procedures, as well as interpret the images and generate a written report. Additionally, the physician
should be capable of assuring the quality of both images and interpretations of the aforementioned procedures.
Privileges include general diagnostic radiology (supervision and interpretation), diagnostic ultrasound, diagnostic nuclear medicine
imaging and therapy, diagnostic magnetic resonance imaging, diagnostic computerized axial tomography, diagnostic neuroradiology,
diagnostic invasive procedures and diagnostic body imaging, as well as image-guided percutaneous biopsies, aspirations and drainage
procedures. These privileges also include the ability to admit and treat patients requiring inpatient care with underlying conditions
that require the services of a radiologist. These privileges do not include any of the following special requests.
These requests are recommended by the Chief of Radiology based on prior education, training and experience.
____ Diagnostic Neuro, Peripheral and Visceral Arteriography (88.40)
____ Angioplasty -- Peripheral, Renal and Visceral (39.RD)
____ Percutaneous Endovascular Stent Placement (ST.RD)
____ Percutaneous Urologic Procedures (UR.RD)
____ Percutaneous Neurointerventional Procedures (NR.RD)
The requisite training or experience for the above procedures consists of either a one-year fellowship in neuroradiology or
interventional radiology, 75 documented angiographic or interventional procedures performed during radiology residency, or 50
such procedures performed in the last two years.
____ Radionuclide Therapy (N50.OR)
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2. The requisite training and experience for the above procedure consists of appropriate training in Nuclear Medicine, as part of an
accredited radiology residency program, and documentation of an average of one procedure performed per six months, or two
procedures per year.
____ Percutaneous Vertebroplasty (PV.RD)
Criteria:Basic education should be MD or DO. Minimal formal training should consist of successful
completion of an accredited Radiology, Orthopaedics, or Neurosurgery residency training program.
And at least one of the following:
1) Physician has attended a course on Vertebroplasty with hands on experience, and has a certificate of satisfactory
2) Physician has completed a residency program, which includes training for Vertebroplasty with documentation of 10 cases
in which the resident was the primary surgeon.
3) Successful performance of at least ten Percutaneous Vertebroplasty procedures in the past twelve months.
Mentoring: Five cases.
Applicants must demonstrate that they have maintained competence by successfully performing at least percutaneous vertebroplasty
procedures in the past twenty-four months.
______ Carotid Stenting ( 00.63 )
The physician providing/performing carotid, vertebral or brachiocephalic angioplasty/stenting must meet one of the following criteria for initial
Qualification by Training: Successful completion of an ACGME/AOA or equivalent accredited fellowship training
program in Endovascular Interventional Neuroradiology and;
Current certification in radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, or
their equivalent, with certification of added qualification (CAQ) in interventional radiology or neuroradiology to be
achieved within five (5) years of initial staff appointment;
Qualification by Experience: Current certification in radiology by the American Board of Radiology, the American
Osteopathic Board of Radiology, or their equivalent, with certification of added qualification (CAQ) in interventional
radiology or neuroradiology to be achieved within five (5) years of initial staff appointment; and,
The physician must provide documentation of satisfactory proctoring and evaluation in the carotid, vertebral or
brachiocephalic angioplasty/stenting of at least of twenty (20) patients. Proctoring must be performed by a qualified
physician. The applicant physician must also meet criteria for acute intraarterial thrombolytic therapy at RRMC.
Qualification by Proctoring: Physician must have certification in radiology by the American Board of Radiology, the
American Osteopathic Board of Radiology, or their equivalent, with certification of added qualification (CAQ) in
interventional radiology or neuroradiology to be achieved within five (5) years of initial staff appointment; and,
The physician must have the first twenty (20) carotid, vertebral or brachiocephalic angioplasty/stenting procedures
performed at RRMC proctored by another physician with current privileges for carotid stenting. The applicant physician
must also meet criteria for acute intraarterial thrombolytic therapy at RRMC.
Mentoring: Physicians qualifying by training or experience will have the first five cases mentored by a physician holding
current privileges for carotid stenting. If no currently privileged physician is available to provide mentorship, the applicant
will submit the first five (5) cases performed for review by a qualified physician holding privileges for carotid stenting at
another institution. The credentials of the mentoring physician shall be subject to approval by the Medical Director of
Radiology and by the Credentials and Privileges Committee.
The physician providing/performing carotid, vertebral or brachiocephalic angioplasty/stenting must meet the following criteria to
demonstrate continued competence:
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3. Maintenance of Privileges: As a condition of obtaining and maintaining privileges, treating physicians agree to collaborate
with other neuroscience physicians involved in the care of patients undergoing carotid stenting with respect to patient
selection, pre/post-procedural neurologic assessment, and outcomes analysis for each procedure performed. Physicians
must participate in the department quality improvement process. For re-certification, physicians must be able to document
satisfactory performance of at least ten (10) carotid stent procedures during the two-year re-certification period.
_______ MODERATE (CONSCIOUS) SEDATION ANALGESIA
This protocol shall assist in determining the competence of non-anesthesiologists (M.D./D.O./D.D.S./D.M.D.) to direct moderate
sedation/analgesia for procedures performed at the hospital. This protocol endorses the ASA Guidelines for Sedation and Analgesia
by Non-anesthesiologists and ASA Physical Status Classes I-IV in determining appropriate candidates for moderate sedation.
1. Eligibility: An individual must meet one of the following prerequisite criteria:
• Have completed an ACGME/AOA residency or oral surgery residency.
• Have attained ABMS Board Certification.
• Maintain a current ACLS Certificate.
2. Training/Experience in Sedation/Analgesia. In addition to A.1, one of the following is required.
• Formal Training: Specialized training in anesthesiology, if attained in an accredited program, as confirmed by the
program director. Eligible Oral Surgeons are deemed to have special training in sedation when a current anesthesiology
permit is maintained.
• Hospital/Privileges: The physician’s approved privileges from a hospital listing sedation/analgesia privileges, or
verification of it from the physician responsible for clinical review (Chairman/Chief/Medical Director).
• Clinical Proficiency: Review of educational and self-assessment materials documenting ability to supervise
sedation/analgesia, to include pharmacology, timely intervention and adverse occurrences.
3. Self-Assessment Proficiency: The applicant will possess proficiency as follows:
• Pharmacology: Familiarity with the pharmacology, contraindications, agonists, and antagonists used for
sedation/analgesia; familiarity with pharmaceutical contraindications and adverse results of agonists and antagonists
(use appendix D of this Policy).
• Didactic Review: Completion of the following:
o RRMC Guidelines/Protocol for Moderate Sedation/Analgesia for Procedures.
o Summary of ASA Guidelines for Sedation and Analgesia by Non-anesthesiologists.
• Successful completion of moderate sedation post test, which evaluates knowledge of pharmacology and didactic
Mentoring and Reappointment
Ongoing proficiency is required to maintain privileges. Mentor reports for concurrently performed invasive procedures may be
accepted to document initial proficiency.
REAPPOINTMENT/CURRENT CLINICAL COMPETENCE:
All members of the Department are reappointed every two years in accordance with the Bylaws and Credentialing Policies of the
Medical Staff. Since reappointment is an affirmation of good clinical practice, each applicant for reappointment will provide
evidence of a sufficient active practice to satisfy the review committees and the Board of Governors that such a judgment can be
made. Applicants must demonstrate that they have maintained competence by successfully performing at least 10 percutaneous
vertebroplasty procedures in the past 24 months.
Note: If any of these requests are covered by an exclusive contractual arrangement, physicians who are not a party to the contract are not eligible
to request privileges regardless of education, training and experience.
Chief, Department of Radiology Date
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4. Date of Recommendation by the Credentials & Privileges Committee: ___________
Date of Recommendation by the Executive Committee: ___________
Date of Approval by the Board of Governors: ___________
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