RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

1 South Street, Kogarah NSW 2217 Ph: 02 9598 5421 Fax: 02 9598 5433

Application for Appointment as an Accredited Practitioner

Practitioner Accreditation Application Form

St George Private Hospital, Kogarah

Thank you for lodging your application for accreditation at St George Private Hospital. St George Private Hospital is a 236 bed acute Surgical and Medical facility with a Level 2 ICU, Level 2 Special Care Nursery, 6 bed Delivery Suite, 19 bed Day Surgery Facility, an Interventional Cardiac Catheter Laboratory, 12 Operating Theatre complex and 3 Endoscopy and minor procedure rooms. This application has been designed based on the clinical scope undertaken at St George Private, and your application will be considered and processed on this basis. If you are requesting a scope of practice beyond the options detailed on pages 4, 5 and 6, you will need to discuss this with the CEO before you lodge your application to ensure the Hospital has the appropriate resources to manage your patient requirements. Any queries or questions regarding this application should be lodged to: Chief Executive Officer St George Private Hospital 1 South Street Kogarah NSW 2217 Ph: Fax: Email: 02 9598 5421 02 9598 5433 [email protected]

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner Application for Appointment as an Accredited Practitioner
I hereby apply to Ramsay Health Care for Appointment as an Accredited Practitioner at St George Private Hospital and seek appointment for the category and privileges indicated. To support my application I submit the following information. (Please Print and attach separate sheets if insufficient space):

1.

Personal Details

Title (eg: Dr, Mr, A/Prof, Prof) Surname: Given Name(s): Any former names
(including maiden name)

Prescriber No.: Provider No.:

Practice Address: Postcode: Telephone: Residential Address: Postcode: Telephone: Facsimile: Date of Birth: Email: Postal Address:
Practice Residential Other details as follows:

Facsimile:

Pager No.: Mobile No.:

Name of Spouse/Partner:
Invitation Purposes only

Postcode:

NB:

IT IS THE APPLICANTS RESPONSIBILITY TO ENSURE ANY CHANGES TO CONTACT INFORMATION IS ADVISED TO THE HOSPITAL IMMEDIATELY.

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner 2. Clinical Privileges & Scope of Practice Please detail scope of Clinical Practice Requested: (Not applicable for Surgical Assistants) NB: Applicants must tick the specialty required and then all relevant subspecialties, privileges are sought in.
Please tick

Categories
Specialist Practitioner (please attach copy of
Medicare Eligibility confirmation letter)

Privileges
Admitting Privileges Consulting Privileges Assist Privileges Anaesthetic Privileges Surgical/Procedural Privileges Diagnostic Privileges Observer only Other

Please tick

Consultant Emeritus (no admitting rights) Fellow Practitioner (no admitting rights) Dentist HMO/CMO (no admitting rights) Surgical Assistant (no admitting rights) General Practitioner (Surgical Assist only no admitting rights) Other

Surgical Assistants only who will you be assisting? _______________________________________ Type of Appointment Required:
Permanent A Permanent appointment covers up to 12 months to 5 years depending on review and approval by the Credentials Committee A Temporary appointment is for a maximum of up to 4 months only commencing from the date of approval given by the CEO A Fixed Term appointment is for a maximum of up to 6 months only and is not continuous beyond this date. Please state the period you require accreditation for: From: _______________________ to ______________________

Temporary

Fixed Term

If you are applying for interventional privileges, such as endovascular, cardiology, radiology and/or laser, advanced endoscopic or laparoscopic surgery, you will need to provide evidence of training and experience as per the relevant College Guidelines for a minimum of 12 months, and copies of licenses, where applicable, such as EPA Radiation License.

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

Not applicable to Surgical Assistants
ANAESTHESIA Adults Neonatal (<1yr old in an
Emergency situation only)

Obstetric Paediatric (>1yr old) Cardiac Adult only Trans-Oesophageal Echo (TOE) - Adult only Chronic Pain Management CARDIAC PERFUSION CARDIOLOGY SEE APPENDIX A Please complete Competencies contained within Appendix A CARDIOTHORACIC SURGERY Adult Only Vascular Procedures Coronary Artery Bypass Off Pump Procedures Minimally Invasive Surgery Arrhythmia Surgery Thoracic Aorta Procedures Thoracic/Lung Procedures Insertion of Pacemaker Other Please Specify: DENTISTRY Adults Paediatric ENT SURGERY Adult Paediatric Adenoidectomy Bronchial Procedures Ear Procedures Facial Nerve Laryngeal Procedures Sinonasal Procedures Otolaryngology-Head & Neck Oral & Oropharyngeal Procedures Tonsillectomy Laryngeal & Tracheal Procedures Other Please Specify:

GASTROENTEROLOGY Diagnostic Upper Gastrointestinal Endoscopy Therapeutic Upper Gastrointestinal Endoscopy Liver Biopsy Enteroscopy Sclerotherapy Oesophageal Banding Placement of Oesophageal Prostheses Oesophageal Dilatation Flexible Sigmoidoscopy Diagnostic Colonoscopy Therapeutic Colonoscopy Endoscopic Retrograde Cholangiopancreatography (ERCP) & Associated Therapeutic Interventions & Biliary Stenting Cholangiogram Percutaneous Endoscopic Gastrostomy (PEG) GENERAL SURGERY Adult Colorectal Surgery Endocrine Surgery Adrenalectomy Thyroidectomy Endoscopic Surgery Gastrointestinal Surgery Laparoscopic Surgery Diagnostic Interventional Upper GI Surgery GENERAL SURGERY - SUBSPECIALTIES Paediatric Breast Surgery Hepatobiliary & Pancreatic Surgery Oesohagectomy Bariatric Surgery
Adults & Adolescents (16-18yrs) Only

GYNAECOLOGY - GENERAL Advanced Endoscopic Surgery Gynaecology General Laparoscopic Surgery Prolapse Surgery Ultrasound GYNAECOLOGY - SUBSPECIALTIES Assisted Reproductive Services (IVF) Gynaecological Oncology Uro-gynaecology INTENSIVE CARE Adults MEDICINE General Medicine Adults Only Dermatology Endocrinology Geriatrics Hepatology Immunology Infectious Diseases Internal Medicine Neurology Oncology
Adults Only Medical Oncology

Radiation Oncology
Provide copy of EPA License

Palliative Care Hematology Rehabilitation Renal Medicine

Nephrology-General Nephrology-Interventional

Respiratory Medicine
Bronchoscopy- Diagnostic BronchoscopyTherapeutic Sleep Medicine o Adult o Paediatric

Lap Banding Modified Roux-en-Y Sleeve Gastrectomy

NB: Paediatric Lap Banding is not permitted at this hospital NB: Scopinaro or Biliopancreatic Bypass is not permitted at this hospital

Rheumatology Other Please specify: NEUROSURGERY Adult Only Nerve Procedures Spinal Procedures

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

Not applicable to Surgical Assistants
OBSTETRICS Maternal Fetal Medicine Obstetrics Ultrasound Uro-gynaecology OPHTHALMOLOGY Adult Paediatric Cataract Surgery Corneal Transplantation Eyelid Surgery Glaucoma Surgery Lacrimal surgery Oculopastic Orbital Surgery Pterygium Surgery Refractive Surgery Squint Surgery Vitreoretinal Surgery ORAL & MAXILLOFACIAL Adult Paediatric Orthognathic Surgery Implant/Pre-Prosthetic Surgery Trauma TM Joint Surgery Oncology ORTHOPAEDICS - GENERAL Adult Paediatric Arthroscopic Surgery Fracture Management Major Joint Replacement ORTHOPAEDICS - SUBSPECIALTY Spinal Surgery Other Please Specify PAEDIATRIC MEDICINE General Medicine Neonatology Level II
(34wks or later)

PLASTIC & RECONSTRUCTIVE SURGERY Adult Paediatric Bat Ears Only Repair of Lacerations Only Revision of Scars Only Abdominal Reductions Augmentation Breast Surgery Cosmetic Rhinoplasty Endoscopic Brow Surgery Facial Surgery Laser Ablation
Provide copy of EPA License

RADIOLOGY SEE APPENDIX B (Continued) Vascular Catheterisation Diagnostic Interventional Nuclear Medicine Adult Paediatric
Anatomical Pathology Conventional Gamma Cameras Positron Emission Tomography (PET)

Liposuction Neurovascular Flaps Other Please Specify:

UROLOGY Adult Paediatric Endoscopic Urology Laparoscopic Urology Laser

Provide copy of EPA License

RADIOLOGY SEE APPENDIX B Diagnostic Imaging Adult Paediatric Bone Mineral Densitometry (BMD) Computerised Tomography (CT Scan) Fluoroscopy Magnetic Resonance Imaging (MRI) Mammography Nuclear Medicine Radiation Oncology Standard Diagnostic Radiography Ultrasound Interventional Radiology Adult Paediatric
Diagnostic
Perform at least 100 procedures/ yr

Open Urological Procedures ESWL

Provide copy of EPA License

Other Please Specify: UROLOGY - SUBSPECIALTY Brachytherapy HiFu Lithotripsy Other - Please Specify: VASCULAR SURGERY Anastomosis Arterial Patch Bypass Decompression Embolectomy Endarterectomy Ligation of Aneurysms Repair Replacement Thrombectomy Vascular Trauma of the following: Abdominal Aortic Mesenteric Open

Other Please Specify: PAEDIATRIC SURGERY Other Please Specify: PATHOLOGY General Pathology Other:

Interventional
Perform at least 175 procedures/ yr

Interventional

Radiology Service
o Tier A o Tier B

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

VASCULAR SURGERY (continued) Axillary, Subclavian Carotid Procedure - Endoluminal Carotid Surgery - Open Please complete Endovascular Competencies See Appendix A AAA Stent Grafts Peripheral Interventions Carotid Interventions Renal Stenting Diagnostic Procedures Femoral Embolisation Procedures Iliac Jugular Renal Temporal

3.

Qualifications
(Please attach any relevant documentation)

Degree/Fellowship

Conferring Body

Year

4.

Details of Membership of Professional Associations

5.

Current Appointments
Appointments

Facility

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

6.

Past Appointments
Appointments

Facility

7. References
Please provide details below for three peer references who can attest that your recent practice is consistent with the criteria contained within the St George Private Hospital Facility Rules. We prefer (where possible) that these references are independent. However, where there is a relationship which can lead to a bias, such as a referee and the applicant are in business together as a partnership or are employer/employee, then this relationship must be disclosed by you to the hospital. The referees provided should be familiar with your current professional capabilities. Please note that your referees will be contacted and asked to provide a reference. The reference should be in writing.

Name Phone: Email: Name Phone: Email: Name Phone: Email:

Address Fax:

Address Fax:

Address Fax:

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

8.

Registration

Please supply details of your current registration with Australian Health Practitioner Regulation Agency (AHPRA). Registration Number: Expiry Date: Conditions: Please attach a copy of the current Registration Certificate
NB: IT IS THE RESPONSIBILITY OF THE PRACTITIONER TO PROVIDE CURRENT COPIES OF MEDICAL REGISTRATION TO THE FACILITY UPON RENEWAL. FAILURE TO DO SO COULD HAVE AN ADVERSE IMPACT ON THE PRACTITIONERS APPOINTMENT.

.. . ...

9.

Insurance
Please refer to RHC Facility Rules 35.2, 49.2, 59.2 and clauses 218.13 and 218.4 of Schedule 1 for professional indemnity insurance requirements for Accredited Practitioners (see definitions - 6.5 and 6.6). Accredited Practitioners must hold professional indemnity insurance cover issued by an Australian insurer. Ramsay policy requires that all Accredited Practitioners hold a minimum level of cover of $20 million for each claim and in the aggregate. Please note the requirement to furnish annually to the Hospital CEO documentary evidence of the level of this cover and also to immediately advise any material changes to the level of cover or conditions of the policy. Please contact the Hospital CEO if you have any queries.

Do you have current Medical Indemnity Insurance at the appropriate level? Please provide details: Insurer: Category of Cover held: Policy No: ..

Yes

No . .. ..

Expiry date: ..

Please attach a copy of your Medical Insurance Policy / Schedule not just your membership card. It is important that the Hospital ascertains the level of your insurance to ensure this sufficiently covers the requested scope of practice.
NB: IT IS THE RESPONSIBILITY OF THE PRACTITIONER TO PROVIDE CURRENT COPIES OF MEDICAL INDEMNITY TO THE FACILITY UPON RENEWAL. FAILURE TO DO SO COULD HAVE AN ADVERSE IMPACT ON THE PRACTITIONERS APPOINTMENT.

If you hold employer indemnification you must ensure you have a portion of cover for private practice.

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner 10. Professional Development

Please provide details (e.g. courses attended relevant to your appointment) of your compliance with the Continuing Education/Professional Development/Recertification or Maintenance of Standards Program of your College. ..

11.

Fluoroscopic X-Ray Equipment

Please Note: All Practitioners operating fluoroscopic x-ray equipment are required to hold a Radiation License with the Environmental Protection Agency (EPA) and have undertaken an approved radiation safety course. Therefore, if applicable to you, please state the following and provide a copy of your current license with your application. N/A License No: Course Date: License held, details as follows: ..Expires: Location: ..

12.

Laser Equipment

Please Note: All Practitioners operating laser equipment are required to hold accreditation to do so, having successfully completed an appropriate training course. Therefore, if applicable to you, please state the following and provide a copy of your accreditation certificate with your application. N/A Certificate No: Course Date: Training completed, details as follows: ..Expires: Location: ..

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner

13.

Disclosure
Yes No

a) Have you ever had any restrictions placed on your Medical Registration?

If you answered yes to the above, please provide details (including details of the restriction and what period during which the restrictions apply/applied): . . b) Have you previously been refused clinical privileges at another health care facility? Yes No .. ..

If you answered yes to the above, please provide name of the facility & rationale for refusal. Please note, a senior executive of the hospital may contact the facility. . . c) Have your clinical privileges ever been withdrawn, suspended or not renewed on the basis of clinical competency at another hospital? Yes No If you answered yes to the above, please provide name of the facility & rationale for refusal. Please note, a senior executive of the hospital may contact the facility. .. .. d) Have there ever been any serious adverse findings made against you which would be relevant to your appointment (for example: breach of insurance / medical laws, professional misconduct, sexual assaults or assault) by the, Health Insurance Commission, a Medical Board, a Health Care Complaints Commission/Body, a Coroner, a Court or any other professional disciplinary or similar body? Yes No If you answered yes to the above, please provide details: .. ... .. ..

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner 13. Disclosure (continued)

e) Criminal Record Check Have you been convicted of or pleaded guilty to a criminal offence including a serious sex or violence offence or an offence involving dishonesty or drugs (other than a spent conviction)? Yes No If you answered yes to the above, please provide details: .. NSW Applicants Only- Working with Children A Working with Children Check is required of applicants in NSW who will be undertaking direct and unsupervised contact with children as a primary function in the course of their work. Are you likely to be undertaking child related work meeting the definition above? Yes No

If you answered yes to the above question, do you consent to make a prohibited Employment Declaration and a Background Check, as prescribed by the relevant law? Yes No

14.

Nomination Alternative in event of A Clinical Emergency

NB: This should not be a relative but an accredited colleague in the same specialty at the same facility.

In the event that I am unable to be contacted for a clinical emergency, the person nominated below is an appropriately qualified Accredited Practitioner at St George Private Hospital, who has agreed to deputise for me. (Please note this is not required for Surgical Assistants): Name: Contact Phone Numbers: . ..

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

St George Private Hospital

Application for Appointment as an Accredited Practitioner 15. Representation and warranty

The information provided by me to Ramsay Health Care in this application and in connection with this application is accurate and complete and is not misleading or deceiving or likely to mislead or deceive. I understand that if I have provided misleading or deceptive information or information which is likely to mislead or deceive that the Board of Ramsay Health Care Pty Limited may (in its absolute discretion) consider that I do not have current fitness under the Hospital Facility Rules. I agree that I will notify the CEO of St George Private Hospital of any material changes to the information provided by me in connection with this application as soon as possible after the change. I understand that my Appointment as a Visiting Medical Officer if granted, will be reviewed in one year or earlier if considered necessary. I acknowledge that I have been provided with, and, read a copy of the Hospital Facility Rules. If appointed, I agree to abide by the policies and Facility Rules of St George Private Hospital.

Signature: ________________________________ Witness Name: ____________________________ Signature: ________________________________ Return to: Chief Executive Officer St George Private Hospital 1 South Street KOGARAH NSW 2217 Phone: Fax:

Date: __________ Date: __________

02 9598 5421 02 9598 5433

Checklist:

Completed Application Current Medical Board Registration Current Resume Current Medical Indemnity Copy of Qualifications EPA Radiation Licence (if applicable) Copy of College Fellowship Current CME Certificate Copy of Letter of Recognition from Medicare Australia for Specialist status

NOTE: If you are applying for privileges for interventional procedures, laser procedures, advanced laparoscopy or Endoscopy, you are required to provide evidence of your training and experience in these areas over the past 12 months minimum.

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

Application for Appointment as an Accredited Practitioner APPENDIX A Competencies

Cardiology / Endovascular
CLINICAL PRACTICE SOUGHT AS THE FOLLOWING SPECIALIST(S) IN THE CARDIOVASCULAR UNIT:
Cardiologist Procedural Cardiologist Interventional Cardiologist Electrophysiologist Endovascular Procedures Diagnostic Procedures Peripheral Interventions Carotid Interventions AAA Stent Grafts Embolisation Procedures Renal Stenting

DETAIL THE AREAS OF CLINICAL PRACTICE REQUESTED:

Cardiology Diagnostic Procedures Interventional Procedures EPS/Ablation Procedures Implantable: Pacemaker Biventricular Pacemaker AICD Trans-oesophageal Echocardiography (TOE) Adult
Only

COMPETENCY GUIDELINES (AS PER CSANZ GUIDELINES): During Training or within the last 5 years of Clinical practice (Did you meet or
exceed these amounts? If not what quantity?)

Current Practice Across all institutions you visit (Do you meet or
exceed these amounts? If not what quantity?)

Cardiology
Diagnostic Procedures Interventional Procedures Electrophysiology Studies Participate in 400 coronary Angiograms Perform 150 cases as supervised operator Perform 150 cases as primary operator Participate in 400 cases (100 complex) Perform 200 cases as primary operator Participate in 150 diagnostic cases Participate in 100 ablation cases Perform 50 cases as primary operator Perform 10 trans-septal catheterisations Perform 75 implants Perform 20 revisions Perform 15 Bi-Ventricular implants 100 cases / year 75 cases / year 50 cases / year (30 as ablations)

Implantable Electronic Devices

(pacemakers and ICDs single, dual & Bi V, active & passive fixation)

Cardiac Interventions
(valvuloplasty, PFO/ASD closures etc)

12 PM & 10 ICD implants / year 5 revisions / year Follow 50 PM & 20 ICD patients / year 5 cases / year 20 cases / year 20 cases / year 10 cases / year 5 cases / year

Endovascular
Perform Angiography Peripheral Interventions Carotid interventions AAA Stent Grafts Perform 100 cases (50 as primary operator) Perform 50 cases (25 as primary operator) Perform 100 Peripheral angiograms (not only
carotids)

Perform 15 cases (10 as primary operator Perform 10 cases (5 as primary operator)

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RAMSAY HEALTH CARE AUSTRALIA PTY LIMITED

ABN 36 003 184 889

Application for Appointment as an Accredited Practitioner APPENDIX B Competencies

Interventional Radiology Service
It has been determined by I.R.S.A. that there are two tiers of interventional radiology. TIER A (Any individual with RANZCR or equivalent qualifications may perform) Basic diagnostic angiography and interventional techniques: Angiography Nephrostomy Abscess drainage Biopsy. TIER B (Evidence is required plus completion of Appendix B) Procedures All neuro-interventional procedures intracranial and extracranial All vascular interventional procedures other than basic diagnostic angiography, i.e. stents, angioplasty, thrombolysis, thrombectomy, atherectomy, embolisation, retrieval of foreign bodies and laser and mechanical angioplasty Venous and arterio-venous graft interventions other than basic diagnostic venography or fistulography, i.e. thrombolysis, angioplasty, stents, atherectomy, pulmonary embolectomy/thrombolysis and caval filter insertion Biliary intervention including T.I.P.S. Thoracic intervention, i.e. embolisation of AVMs, bronchial stents, occlusion of broncho-pleural fistulae and bronchial artery embolisation Gastro-intestinal intervention, i.e. oesophageal and duodenal stents, percutaneous gastrostomy, gastrointestinal vascular procedures other than diagnostic angiography, i.e. embolisation, chemoembolisation and transplant intervention. Urological intervention, i.e. renal artery embolisation, angioplasty or stenting, percutaneous nephrolithotomy Gynaecological - fallopian tube recanalisation, embolisation of fibroids, temporary aortic occlusion Orthopaedic - percutaneous vertebroplasty, percutaneous discectomy Minimum Training Requirements/Evidence: Performance of 300 peripheral angiograms under accredited supervision Performance of 50 peripheral/renal angioplasties with 25 as primary operator, with at least 10 using an antegrade femoral approach Performance of 30 vascular stents (15 as primary operator) Performance of 20 cases of peripheral vascular thrombolysis (10 as primary operator) Performance of 10 cases of peripheral catheter guided thrombus aspiration (5 as primary operator) Ultrasound guided vessel puncture (20 cases as primary operator) Completion of an approved course in radiation biology and protection equivalent to that provided to F.R.A.N.Z.C.R. candidates These procedures should have been performed in an I.R.S.A./ R.A.N.Z.C.R accredited site open to peer review and audit with indications, primary success and complications documented. Combined procedures are to be counted as one procedure with the exception of ultrasound guided punctures. (Angiogram + angioplasty + stent + aspiration + thrombolysis = one procedure)

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