N.J. Admin. Code § 13:35-4A.12

Current through Register Vol. 56, No. 9, May 6, 2024

Section 13:35-4A.12 - Alternative privileging procedure

(a) A practitioner who seeks to provide or supervise the administration and monitoring of general or regional anesthesia, as well as moderate sedation, in an office, but does not hold privileges at a licensed hospital or ambulatory surgery center to do so, shall submit, to the Board, an application for these privileges. To be eligible to apply for these privileges, an applicant shall meet the following criteria and submit an application that documents the applicant's fulfillment of these criteria:

1. Demonstration of clinical experience, through an attestation as to the number of procedures for which general or regional anesthesia was provided by the applicant in the last two years for all age groups of patients within the applicant's practice for which privileges are requested;

2. Any one of the following:

i. Current certification in anesthesiology granted by the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology or any other certification entity that the applicant demonstrates has standards of comparable rigor;

ii. Successful completion of a residency training program in anesthesiology accredited by the Accreditation Council on Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA); or

iii. Supervised training in residency, fellowship or other equivalent experience in another field and active participation in the examination process leading to certification in anesthesiology; and

3. Possess clinical competence to perform the anesthesia services or procedures authorized by the requested privileges, with such competence confirmed by the following:

i. Three references submitted directly by plenary licensed physicians addressing the applicant's current competence based on personal knowledge obtained either during a residency training completed during the two years preceding the application or through personal observation during the two years preceding the application;

ii. Submission of a log listing all patients for whom the applicant provided any of the anesthesia services in an office setting or licensed ambulatory care facility setting for which privileges have been requested during the two years preceding the date of the application. The log shall include a patient number, the type of anesthesia service provided, the surgery or special procedure performed and the date(s) of service. Patient names and other identifying data shall be redacted. The applicant shall maintain a list or other means to identify the patient, based on the number included in the log;

iii. Identification of any patients in the log who have experienced complications relating to the applicant's provision of anesthesia services in an office setting or licensed ambulatory care facility setting and their resulting outcomes; and

iv. Submission of no fewer than five patient records or charts (or the pertinent portions thereof with patient names redacted) which have been identified and requested by the Board or other reviewing entity, designated pursuant to (e) below, along with a completed case summary form for each submitted case, utilizing such forms as are provided in the application materials.

(b) A practitioner who seeks to administer or supervise the administration and monitoring of only moderate sedation in an office, but does not currently hold clinical privileges at a licensed hospital or ambulatory surgery center to do so, shall submit, to the Board, an application for this privilege. To be eligible to apply for this privilege, an applicant shall meet the following criteria and submit an application that documents the applicant's fulfillment of these criteria:

1. Demonstration of clinical experience, through an attestation as to the number of procedures for which moderate sedation was provided by the applicant in the last two years for all age groups within the applicant's practice of patients for which privileges are requested, except age groups as are specifically excluded from the applicant's practice;

2. Any one of the following:

i. Current certification in anesthesiology granted by the American Board of Anesthesiology or the American Osteopathic Board of Anesthesiology or any other certification entity the applicant demonstrates has standards of comparable rigor;

ii. Current certification in Critical Care Medicine or Emergency Medicine by a specialty board or certifying entity recognized by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) or any other certification entity the applicant demonstrates has standards of comparable rigor; or

iii. Satisfactory evidence that the applicant is advanced cardiac life support trained with updated training from a recognized accrediting organization and either:

(1) Successful completion of an educational home study program, with a test of basic knowledge obtained from the Board; or

(2) A course in moderate sedation offered by a licensed hospital or for continuing medical education credits; and

3. Submission of a list of all patients who have experienced complications relating to the applicant's provision of moderate sedation in an office setting or licensed ambulatory care facility setting and their resulting outcomes. Patient names and other identifying data shall be redacted. The applicant shall maintain a list or other means to identify the patient, based on the number included in the log.

(c) A practitioner who seeks to perform surgery (other than minor surgery) or special procedures in an office, but does not hold privileges at a licensed hospital or ambulatory surgery center to perform these procedures shall submit, to the Board, an application for these privileges, including a completed privilege request form appropriate to the privileges requested. To be eligible to apply for this privilege, an applicant shall meet the following criteria and submit an application that documents the applicant's fulfillment of these criteria:

1. Demonstration of clinical experience, through an attestation as to the number and type of procedures performed by the applicant in the last two years for all age groups of patients for which privileges are requested;

2. Any one of the following:

i. Current certification in the field(s) of practice in which the privileges are sought granted by a specialty board or certifying entity recognized by the American Board of Medical Specialties (ABMS), the American Osteopathic Association (AOA), the American Podiatric Medicine Association (APMA) or any other certification entity that the applicant demonstrates has standards of comparable rigor;

ii. Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) residency or fellowship training program in the field(s) of practice in which privileges are sought; or

iii. Supervised training in a residency or fellowship training or other equivalent experience in another field and active participation in the examination process leading to certification in the practice field(s) in which privileges are sought; and

3. Possess clinical competence to perform the procedures authorized by the requested privileges, with such competence confirmed by the following:

i. Three references submitted directly by plenary licensed physicians (or licensed podiatrists as to podiatric applicants) addressing the applicant's current competence based on personal knowledge obtained either during a residency training completed during the two years preceding the application or through personal observation during the two years preceding the application;

ii. Submission of a log listing all patients for whom the applicant has performed surgery or special procedures in an office setting or licensed ambulatory care facility setting for which privileges have been requested during the two years preceding the date of the application. The log shall include a patient number, the surgery or special procedure performed and the indications for that procedure and the date(s) of service. Patient names and other identifying data shall be redacted. The applicant shall maintain a list or other means to identify the patient, based on the number included in the log;

iii. Identification of any patients in the log who have experienced complications relating to the applicant's performance of surgery or special procedures in an office setting or licensed ambulatory care facility setting and their resulting outcomes; and

iv. Submission of no fewer than five patient records or charts (or the pertinent portions thereof with patient names redacted) which have been identified and requested by the Board or other reviewing entity, along with a completed case summary form for each submitted case, utilizing such forms as are provided in the application materials.

(d) A practitioner who seeks to utilize laser surgery techniques in an office, but does not hold privileges at a licensed hospital or an ambulatory surgery center to do so, shall submit, to the Board, an application, which shall include:

1. Certification of successful completion of an accredited laser training program, in which the curriculum includes instruction in laser care, physics and clinical indications for utilization of the specific laser; or

2. Documentation from the program director of an accredited residency training program which the applicant has successfully completed, attesting to the inclusion of training in the specific laser therapy for which privileges are being sought during residency training.

(e) The Board may delegate to a reviewing entity the responsibility to conduct a preliminary review of an application to ascertain whether the applicant has met the criteria established in (a) through (d) above, which review shall be undertaken at the expense of the applicant. The Board shall thereafter review the summary report including any recommendation concerning the applicant prepared by the reviewer and make a decision on the application for privileges.

(f) If the Board or any entity or person to which the Board may delegate the preliminary application review finds that the applicant has not submitted sufficient information upon which a determination as to the applicant's current competence may be made, the Board or the reviewing entity may require:

1. A personal interview;

2. The submission of a representative sample of patient records substantiating the experience of the applicant;

3. The submission of any patient records relating to an identified complication;

4. An inspection of the office, which may include a review of additional patient records and written policies and procedures; and/or

5. The submission of such additional information as may be necessary to determine an applicant's clinical competence to perform the privileges requested.

(g) Upon review of the summary report prepared by the Board or the reviewing entity, the Board may take any of the following actions:

1. Grant all or some of the privileges requested;

2. Condition its approval of all or some of the privileges requested on the applicant's successful completion of additional training;

3. Condition its approval of all or some of the privileges on the applicant's successful completion of a period of observation;

4. Deny all or some of the privileges requested; and/or

5. Require such additional information as may be necessary to act on the application.

(h) Practitioners who have been granted privileges through the alternative privileging procedure of this section shall submit a renewal application to the Board within two years from the date on which privileges were granted. Practitioners shall notify the Board within 21 days should there be any change in the information provided in the application and renewal.

N.J. Admin. Code § 13:35-4A.12

New Rule, R.2002 d.404, effective 12/16/2002.
See: 33 N.J.R. 3870(a), 34 N.J.R. 4449(a).

Amended by 53 N.J.R. 2013(a), effective 12/6/2021