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NEPHROLOGY CLINICAL PRIVILEGES
Name:
Page 1
All new applicants must meet the following requirements as approved by the Board of Directors effective:
____/____/______.
Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing
information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical
activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.
Other Requirements
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Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficient
space, equipment, staffing, and other resources required to support the privilege.
This document is focused on defining qualifications related to competency to exercise clinical privileges.
The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements
that the organization is obligated to meet.
QUALIFICATIONS FOR NEPHROLOGY
Initial Applicants: To be eligible to apply for privileges in nephrology, the initial applicant must meet the following
criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American
Osteopathic Association (AOA) accredited fellowship in nephrology.
AND
Current subspecialty certification in nephrology by the American Board of Internal Medicine or the American
Osteopathic Board of Internal Medicine; OR Obtain certification within no longer than six (6) years from the date of
the completion of residency or sub-specialty training and be recertified as per the timing required by the specific
board. (The board certification requirement is applicable to Physicians applying for initial appointment after October
31, 2003).
AND
Required Current Experience: Demonstrate current competence and evidence of inpatient or consultative
services for at least 24 patients, reflective of the scope of privileges requested, during the past 12 months or
successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.
Reappointment (Renewal of Privilege) Requirements: To be eligible to renew privileges in nephrology, the
applicant must meet the following criteria:
Maintenance of Board Certification, where applicable, is required.
Current demonstrated competence and an adequate volume of experience inpatient or consultative services to 48
patients with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on
results of ongoing professional practice evaluation and outcomes.
Evidence of current physical and mental ability to perform privileges requested is required of all applicants for
renewal of privileges.
Key: CHSA=Children’s Hospital of San Antonio / CSR-AH= CHRISTUS Santa Rosa – Alamo Heights
CSR= CHRISTUS Santa Rosa / MC= Medical Center / NB=New Braunfels / WH=Westover Hills
The Greeley Company © 2014
NEPHROLOGY CLINICAL PRIVILEGES
Name:
Page 2
CORE PRIVILEGES – NEPHROLOGY
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
Admit, evaluate, diagnose, treat, and provide consultation to adolescent and
adult patients, presenting with illnesses and disorders of the kidney, high
blood pressure, fluid and mineral balance, and dialysis of body wastes when
the kidneys do not function. May provide care to patients in the intensive care
setting in conformance with unit policies. Assess, stabilize, and determine
disposition of patients with emergent conditions consistent with medical staff
policy regarding emergency and consultative call services. The core
privileges in this specialty include the procedures listed below and such other
procedures that are extensions of the same techniques and skills.
CORE PROCEDURE LIST
This list is not intended to be an all-encompassing procedure list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and
inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not
wish to request, initial, and date.
Nephrology
1. Perform history and physical exam
2. Acute and chronic hemodialysis
3. Continuous renal replacement therapy
4. Percutaneous biopsy of both autologous and
transplanted kidneys
5. Peritoneal dialysis
6. Placement of temporary vascular access for
hemodialysis and related procedures
7. Image guided techniques as an adjunct to
privileged procedures
QUALIFICATIONS FOR INTERVENTIONAL NEPHROLOGY
Initial Applicants: To be eligible to apply for privileges in interventional nephrology, the initial applicant must be
granted privileges in nephrology and have completed post graduate training in interventional nephrology or the
equivalent in hands on training and practice experience. Training should include at a minimum:

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

Angiography of peripheral hemodialysis vascular access to include fistula cases as well as AV grafts – 25
cases
Angioplasty of peripheral hemodialysis vascular access to include fistula cases as well as AV grafts – 25
cases
Thrombolysis/Thrombectomy of peripheral hemodialysis vascular access to include fistula cases as well as
AV grafts – 25 cases
Placement of non-tunneled short-term, hemodialysis catheters – 25 cases
Insertion of tunneled cuffed long-term catheters – 10 cases
AND
Required Current Experience: Demonstrate current competence and evidence of at least 100 interventional
nephrology procedures, reflective of the scope of privileges requested, during the past 12 months or successful
completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.
Key: CHSA=Children’s Hospital of San Antonio / CSR-AH= CHRISTUS Santa Rosa – Alamo Heights
CSR= CHRISTUS Santa Rosa / MC= Medical Center / NB=New Braunfels / WH=Westover Hills
The Greeley Company © 2014
NEPHROLOGY CLINICAL PRIVILEGES
Name:
Page 3
Reappointment (Renewal of Privilege) Requirements:
nephrology, the applicant must meet the following criteria:
To be eligible to renew privileges in interventional
Current demonstrated competence and an adequate volume of experience 200 interventional nephrology
procedures with acceptable results in the privileges requested for the past 24 months based on results of ongoing
professional practice evaluation and outcomes.
Evidence of current physical and mental ability to perform privileges requested is required of all applicants for
renewal of privileges.
CORE PRIVILEGES – INTERVENTIONAL NEPHROLOGY
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
Admit, evaluate, diagnose, treat, and provide consultation to adolescent and
adult patients, presenting with illnesses and disorders of the kidney, high
blood pressure, fluid, and mineral balance, and dialysis of body wastes when
the kidneys do not function. Diagnose problems, individualize treatment,
perform procedures, and recognize and manage complications related to
dialysis access. May provide care to patients in the intensive care setting in
conformance with unit policies. Assess, stabilize, and determine disposition
of patients with emergent conditions consistent with medical staff policy
regarding emergency and consultative call services. The core privileges in
this specialty include the procedures on the attached procedure list and such
other procedures that are extensions of the same techniques and skills.
CORE PROCEDURE LIST
This list is not intended to be an all-encompassing procedure list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and
inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not
wish to request, initial, and date.
Interventional Nephrology
1. Perform history and physical exam
2. Central venous dialysis catheters: non-tunneled short-term catheter placement, tunneled cuffed long-term
catheter placement
3. Image guided techniques as an adjunct to privileged procedures
4. Peripheral dialysis vascular access: angiography, angioplasty, thrombolysis (endovascular thrombectomy)
CHECK HERE TO REQUEST INTERNAL MEDICINE PRIVILEGES FORM.
 Requested
SPECIAL NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA)
Non-Core Privileges are requested individually in addition to requesting the core. Each individual requesting NonCore Privileges must meet the specific threshold criteria as applicable to the initial applicant or re-applicant.
Key: CHSA=Children’s Hospital of San Antonio / CSR-AH= CHRISTUS Santa Rosa – Alamo Heights
CSR= CHRISTUS Santa Rosa / MC= Medical Center / NB=New Braunfels / WH=Westover Hills
The Greeley Company © 2014
NEPHROLOGY CLINICAL PRIVILEGES
Name:
Page 4
MEDICAL MANAGEMENT OF THE KIDNEY TRANSPLANT PATIENT
Criteria: Successful completion of an ACGME- or AOA-accredited fellowship in nephrology. Required Current
Experience: Demonstrated current competence and evidence of the medical management of at least ten (10)
kidney transplant patients in consultation with a surgeon in the past 12 months or completion of training in the past
12 months. Renewal of Privilege: Demonstrated current competence and evidence of the medical management
of at least 20 kidney transplant patients in consultation with a surgeon in the past 24 months based on results of
ongoing performance practice evaluation and outcomes.
Requested
CHSA
CSR - AH
Evaluation of recipients/donors, diagnosis, and treatment of rejection,
diagnosis, and treatment of disorders of transplant function.
CSR
MC
NB
WH
PLACEMENT OF ENDOVASCULAR STENTS
Criteria: Successful completion of an accredited fellowship in interventional nephrology that included training in
endovascular stents or completion of a hands on CME that included the placement of at least 5 endovascular
stents under the supervision of a qualified interventionalist. Required Current Experience: Demonstrated current
competence and evidence of the placement of at least three (3) endovascular stents in the past 12 months or
completion of training in the past 12 months. Renewal of Privilege: Demonstrated current competence and
evidence of the placement of at least five (5) endovascular stents in the past 24 months based on results of
ongoing performance practice evaluation and outcomes. Source: ASDIN Application for Certification in
Interventional Nephrology 10/08
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
PLACEMENT OF SUBCUTANEOUS PORTS
Criteria: Successful completion of an accredited fellowship in interventional nephrology that included training in
endovascular stents or completion of a hands on CME that included the placement of subcutaneous ports in at
least 5 patients under the supervision of a qualified interventionalist. Required Current Experience:
Demonstrated current competence and evidence of the placement of subcutaneous ports in at least three (3)
patients in the past 12 months or completion of training in the past 12 months. Renewal of Privilege:
Demonstrated current competence and evidence of the placement of subcutaneous ports in at least five (5) patients
in the past 24 months based on results of ongoing performance practice evaluation and outcomes. Source: ASDIN
Application for Certification Application Guidelines 2013
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
Key: CHSA=Children’s Hospital of San Antonio / CSR-AH= CHRISTUS Santa Rosa – Alamo Heights
CSR= CHRISTUS Santa Rosa / MC= Medical Center / NB=New Braunfels / WH=Westover Hills
The Greeley Company © 2014
NEPHROLOGY CLINICAL PRIVILEGES
Name:
Page 5
ADMINISTRATION OF SEDATION AND ANALGESIA
Criteria: Successful completion of an approved airway management module or ACLS and documentation of
training in Procedural Sedation by achieving completion of the “Sedation and Anesthesia Care” self-study module
with a score of 80% or higher. Required Current Experience: Demonstrated current competence and evidence
of the performance of at least ten (10) cases of procedural sedation in the past 12 months or completion of training
in the past 12 months with documentation of procedural sedation cases during training. Renewal of Privilege:
Demonstrated current competence and evidence of the performance of at least ten (10) cases of procedural
sedation in the past 24 months based on results of ongoing professional practice evaluation and outcomes.
See Hospital Policy for Sedation and Analgesia by Non-Anesthesiologists
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
ACKNOWLEDGMENT OF PRACTITIONER
I have requested only those privileges for which by education, training, current experience, and demonstrated
performance I am qualified to perform and for which I wish to exercise at CHRISTUS Santa Rosa, and I understand
that:
a. In exercising any clinical privileges granted, I am constrained by Hospital and Medical Staff policies and rules
applicable generally and any applicable to the particular situation.
b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation
my actions are governed by the applicable section of the Medical Staff Bylaws or related documents.
Signed
Date
Key: CHSA=Children’s Hospital of San Antonio / CSR-AH= CHRISTUS Santa Rosa – Alamo Heights
CSR= CHRISTUS Santa Rosa / MC= Medical Center / NB=New Braunfels / WH=Westover Hills
The Greeley Company © 2014