Important Facts and Procedure Privileging for Advanced Residents and Subspecialty Fellows

Important Facts Regarding Privileging

What is the law?

The New York State Health Code 405.4 requires that all residents have direct supervision during their performance of treatments/procedures unless they have been awarded privileges to perform these treatments/procedures under general supervision.

What is supervision?

According to the regulations of the N.Y.S. Health Code," ... supervision shall be provided by physicians who are board certified or admissible in those respective specialties or who have completed a minimum of four post-graduate years of training in such specialty". Supervisory status is determined by the Chairmen of every clinical department. It is the responsibility of the resident to ensure that appropriate supervision, as defined in the N.Y.S. Health Code laws, is available before performing any treatments/procedures for which supervision is required.

What is direct supervision?

Direct supervision is when a teaching staff physician, as outlined in #2 above, is present during the performance of a treatment/procedure and certifies the quality of the performance of that procedure.

What is general supervision?

General supervision is when a teaching staff physician of appropriate expertise, as outlined in #2 above, is in the vicinity and immediately available to consult or to assist with the procedure.

Are there legal ramifications for performing non-privileged procedures without direct supervision?

The Medical Staff of the hospital where service is being provided can take disciplinary action or other corrective measures against any individual providing service when services provided exceed scope of privileges granted.

 

Procedure and Process

1. All fellows must be privileged in procedures required of graduating residents in their core discipline.
   • Fellows who successfully completed their core discipline residency at SUNY Downstate will have their core’s privileges recorded in their fellowship New Innovation procedure logger record.
2. Fellows who have completed their prior core discipline residency training at a non-SUNY Downstate institution must present verifiable documentation of the privileges granted by their prior core discipline residency program(s) to the GME Office and to the Fellowship Director for certification before fellowship training can begin at any SUNY Downstate affiliate hospital.
   • Any SUNY Downstate core discipline procedures not privileged in prior training at a non-SUNY Downstate program must be approved for privileging by the Fellowship Program Director and the core discipline Program Director before fellowship training can begin at any SUNY Downstate affiliate hospital.
   • If the fellow has not been privileged by another institution, the Program Director has the right to modify that resident’s procedure credentialing process after reviewing the nature of that resident’s prior training and clinical experience.
3. Procedure Privileging Specific to Subspecialty Programs
   • Fellowship Program Directors must formally notify the GME Office if the specialty program has procedures which require approval for privileging. If the fellowship program requires approval for privileging of specialty specific procedures, the specialty program will be responsible for assuring that procedures are entered into and updated in the RMS (New Innovations)
   • If the fellowship program does not require privileging approval for any specialty specific procedure, the Fellowship Program Director must formally notify the GME Office that no procedure privileges are required.
4. Though the manner in which the fellow is privileged may be different than a resident entering at the first year level, it will still be necessary for the Program Director to maintain on file any internal or external documentation of the privileging process for that resident and to provide the resident with a letter stating that they have been privileged for performing procedures. A copy of that letter must be sent to the Office of Graduate Medical Education.
5. Procedures and Privileges should be kept up to date in the New Innovations software.

 

Approved by GMEC 4/5/2006
Reviewed and re-approved 6/16/10