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How to keep your sedation privileges active

17 Apr 2016

By: Angie Anderson, MD, chief of anesthesiology; Ralph Yates, MD, chief medical officer, Andrew Furman, MD, vice president medical affairs

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Some of the medical staff have non-core privileges for moderate or deep sedation. If you do, you will soon be assigned a mandatory HealthStream module that includes the updated sedation policy, an SBAR explaining key points concerning the policy, a copy of the audit tool, and an attestation form that must be completed by May 15.

It is important to clarify some important points about the Salem Health sedation policy as it relates to your practice and some actions that will be put in place to create a system to support physician and hospital compliance to the policy.

It has always been a requirement that the provider doing a procedure under moderate or deep sedation documents a pre-procedure assessment that includes ASA score before the procedure starts, and a post-procedure assessment after the procedure is completed. In evaluating physician practice here, this requirement is not consistently met.  The Anesthesiology Department has responsibility for oversight and audits of sedation practices and adherence to policies that govern sedation to ensure regulatory compliance and safe patient care.

Consequences for non-completion of the mandatory HealthStream module by May 15 will be suspension of sedation privileges until completed.

Consequences of failing the audit process after May 16 will be email communication of the failure, continued audits, and a meeting with the anesthesiology section chief if the failures continue.

This is meant to be helpful, not punitive.  We have been cited by The Joint Commission in the past so we would like to keep all physicians informed and in compliance with our policy.