Delineation of Privileges
                      Department of Pediatrics/Division of Pediatric Neurology

                ...
considered in individual cases as equivalent to
                                                                   above.
...
Requeste Granted Privileges                                       Minimum Training and Experience
   d
                   ...
q           q




TO BE COMPLETED BY APPLICANT:

I authorize and release from liability, any hospital, licensing board, ce...
EXECUTIVE COMMITTEE ON CLINICAL AFFAIRS ACTION:

Approval:         As Requested                Disapproved, explain

Execu...
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Delineation of Privileges Department of Pediatrics/Division ...

  1. 1. Delineation of Privileges Department of Pediatrics/Division of Pediatric Neurology Applicant’s Name Date First MI Last Instructions: Check the box corresponding to the privileges that you are requesting. Applicants requesting privileges should only request those privileges when the minimum criteria has been met. Minimum threshold for requesting core privileges in Department / Service q I meet the following mentioned minimum criteria and request that my application be considered for the privileges as outlined below. LEVEL I Requeste Granted Scope of Practice / Privileges Minimum Training and Experience d q q Generally, the neurologist must be able to: (1) 1. M.D. or D. O. Is necessary localize a neurologic lesion on the basis of the 2. Minimum of one year of pediatric training in history and examination; (2) develop a an accredited residency program. provisional diagnosis and differential diagnosis; 3. Completion of a second year of pediatric (3) decide on utilization of tests for further training in an accredited residency program or evaluation of the illness; (4) communicate a completion of a year of relevant neuroscience plan with the patient and/or responsible research or completion of a year of internal caregiver and the referring physician; (5) medicine training. review and interpret any additional tests 4. Successful completion of a three-year ordered; (6) render a final therapeutic plan. In pediatric neurology fellowship in an accredited general, all neurologists should be skilled in the program. interpretation of lumbar punctures and can 5. Must be Board eligible or Board certified in interpret and incorporate into the evaluation the Neurology with special competence in child results of the following studies: EMG, EEG, neurology. routine x-rays, CT, MRI, arteriography, and myelography. Pediatric neurologists should be New faculty able to care for any patient aged 18 years or Must be Board certified within 3 years of younger. appointment. Individual neurologists may be appropriately Current faculty: credentialed to perform a number of The minimum level of experience expected in subspecialty areas. These areas and neurology is evaluation of 24 patients in 12 credentialing procedures are described below. months on an inpatient service, or 50 outpatients in an outpatient clinic. Note: training, experience and/or board certification in relevant areas may be Page 1 of 5 3/7/00
  2. 2. considered in individual cases as equivalent to above. LEVEL II Requeste Granted Privileges Minimum Training and Experience d q q To practice within Pediatric Neurology’s All faculty must meet Level 1 minimum training Epilepsy program. and experience requirements. The candidate must have successfully completed EEG: The above named neurologist is an Epilepsy/EEG fellowship. The physician should expected to read EEG, evoked potentials, be board certified by the American EEG Society, sleep, or epilepsy studies. or have certification in neurology with added qualifications in clinical neurophysiology through the American Board of Psychiatry and Neurology, or should be within three years of completion of a fellowship in this area. A minimum one year fellowship is generally required, but may be waived if the applicant has sufficient clinical experience and is working toward Board certification. q q To practice within Pediatric Neurology’s All faculty must meet Level 1 minimum training Neurometabolic Disease program and experience requirements. The successful candidate must have training in neurogenetics, developmental neuroscience or neurochemistry or have equivalent clinical Page 2 of 5 3/7/00
  3. 3. Requeste Granted Privileges Minimum Training and Experience d experience in the biochemical diagnosis and long- term treatment of children with inherited metabolic disorders that affect the central nervous system. For new faculty: Five cases proctored by a faculty member with expertise in Neurometabolic Diseases. q q To practice within Pediatric Neurology’s All faculty must meet Level I minimum training Neuro-oncology program and experience requirements. The successful candidate must have specialized training in neuro-oncology, including experience in the independent administration and monitoring of chemotherapy infusions. For new faculty: Five cases proctored by a faculty member with expertise in Neuro-oncology. q q To practice within the Pediatric Neurology Faculty must meet Level 1 minimum training and Sleep Disorders Program. The above named experience, and the candidate must have formal neurologist is expected to interpret sleep training in sleep medicine. The physician should be studies. board certified in sleep medicine within 3 years of completion of training. For new faculty: Five cases proctored by a faculty member with expertise in Neurological sleep disorders. LEVEL III Requeste Granted Scope of Practice / Privileges Minimum Training and Experience d Page 3 of 5 3/7/00
  4. 4. q q TO BE COMPLETED BY APPLICANT: I authorize and release from liability, any hospital, licensing board, certification board, individual or institution who in good faith and without malice, provides necessary information for the verification of my professional credentials for membership to the Medical Staff of The University of Michigan Health System. Applicant Signature: Date: DEPARTMENT ACTION: Approval: As Requested As modified, explain I have reviewed and/or discussed the privileges requested and find them to be commensurate with his/her training and experience, and recommend that his/her application proceed. Justification for approval is based on careful review of the applicant’s education, postgraduate clinical training, demonstrated clinical proficiency and Board Certification or qualifications to sit for the Boards. Department Chair: Date Service Chief: Date CREDENTIALS COMMITTEE ACTION: Approval: As Requested Disapproved, explain Credentials Committee Member: Date Page 4 of 5 3/7/00
  5. 5. EXECUTIVE COMMITTEE ON CLINICAL AFFAIRS ACTION: Approval: As Requested Disapproved, explain Executive Committee On Clinical Affairs Member: Date Page 5 of 5 3/7/00

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