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Local Recovery Surgeon Verification (3.01)

Local Recovery Surgeon Verification (3.01) - Policies, Clinical, UWHC Clinical, Department Specific, UW Organ and Tissue Donation

3.01



POLICY
Established Date: November 2001
Effective Date: January 2018
Title: Local Recovery Surgeon Verification Policy Number: 3.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 1 of 2
PURPOSE

The purpose of this policy is to outline the process for approving University of Wisconsin Health (UW
Health) recovery surgeons as eligible to perform organ recoveries on behalf of the University of Wisconsin
Organ and Tissue Donation (UW OTD) on a routine basis in hospitals in the UW OTD designated service area
(DSA). It is the policy of UW OTD to require all UW Health (also referred to as “local”) recovery surgeons
who perform organ recovery procedures to obtain approval by the UW OTD medical director. The decision
to approve and renew a local recovery surgeon’s privileges is based on training and adherence to all
applicable regulatory requirements and UW OTD policies.

FORMS

UW OTD Clinical Privileges Form

POLICY

A. Local recovery surgeons will request organ recovery clinical privileges and will provide their
medical license number and/or certifications to UW OTD.
B. A UW OTD medical director (MOC) will review and verify the clinical qualifications of all local
recovery surgeons based on the surgeon’s education and licensure.
C. The MOC will approve local recovery surgeons as qualified to procure organs.
D. Qualified local recovery surgeons will be defined as category I,II, III, or IV.
1. Category I: Members of the UW Health medical staff credentialed by the University of
Wisconsin Hospital and Clinics (UWHC) Credentials Committee to procure organs.
2. Category II: Physician assistants approved by the UWHC Credentials Committee to
procure organs.
3. Category III: Members of the University of Wisconsin (UW) Transplant Program surgical
fellowship training program that are board certified or board eligible in general surgery.
4. Category IV: Physicians who have completed a general surgery training program as well
as a formal surgical transplant fellowship or physicians who have completed a general
surgery training program with advanced knowledge and experience in the multi-organ
procurement recovery procedure. Additionally, he/she will be approved by the UWHC
Credentials Committee.



POLICY
Established Date: November 2001
Effective Date: January 2018
Title: Local Recovery Surgeon Verification Policy Number: 3.01

Electronically Approved By: Michael E. Anderson, PA-C Anthony M. D’Alessandro, M.D.
Executive Director Medical Director


Page 2 of 2
E. The MOC or designee will ensure all local recovery surgeons have a signed clinical privileges
form on file with UW OTD. The signed forms will be filed at the UW OTD office.
F. The initial approval for a local recovery surgeon to procure organs on behalf of UW OTD will be
for a period of one year.
G. The MOC will review local recovery surgeon performance on an on-going basis.
1. Deceased organ donors will be reviewed on a weekly basis during the UW Transplant
Program morbidity and mortality (M&M) conference.
2. Surgical errors will be reported at the discretion of the surgical recovery manager as an
occurrence per UW OTD Policy 1.08, discussed at the M&M conference and reviewed by
the MOC.
H. Renewal of organ recovery clinical privileges will occur every year on a continuing basis. Each
local recovery surgeon will be asked to provide updated requests for clinical privileges and the
MOC will review his/her performance.
I. The MOC may restrict or revoke approval of any local recovery surgeon privileges following a
violation of any UW OTD policy or if there is a change in the local recovery surgeon’s
performance or licensure.
J. At least annually or when a change in credential status occurs, the UW OTD surgical recovery
manager will update the credentials for local recovery surgeons in the Association of Organ
Procurement Organization Credentials Information Network (ACIN) verification system.
K. At least annually or when a change in credential status occurs, the UW OTD surgical recovery
manager or designee will communicate the credential status and details of the local recovery
surgeons with UW OTD staff.


REFERENCES

UW OTD Policy 1.08