Effective January 1, 2019, The Joint Commission (TJC) enacted new requirements for evidence of training in fluoroscopy for physicians, practitioners, and associates.

All physicians and practitioners using fluoroscopy are required to comply with these requirements to continue use of fluoroscopy in their practice. If you are in receipt of this memorandum and DO NOT use fluoroscopy in your practice you may ignore this communication. 

These new and revised fluoroscopy requirements were developed based on risks identified by diagnostic imaging experts, accredited ambulatory care and hospitals, and professional organizations such as the American College of Radiology. Complying with these new requirements will help us provide safe, effective patient care. 

To help meet this requirement, Ascension developed a specific training module for fluoroscopy. This module meets all the training elements identified by TJC and can be accessed via the following link: https://redcap.ascension.org/ahnat/surveys/?s=H878M4TPJ3

Please note when you log on via this link, you will need to select the  following option:

WIMIL – Wisconsin Milwaukee & Racine (includes our legacy Columbia St Mary’s and legacy Wheaton Hospitals)

After completing the training and post-test, you will receive a certificate that must be submitted. Options to submit include:
1. Medical Staff Office at your primary Ascension hospital, or
2. scanned to The Medical Staff Office at SEWIMSO@ascension.org .

Please be sure to print off the certificate acknowledging completion of the education and submit using one of the options identified above.

All physicians requesting privileges for the operation of Class 3b and Class 4 Laser Systems at Columbia St. Mary's Hospitals are required to review the Laser Safety training materials and successfully complete the Laser Privilege test in addition to meeting the minimum personal qualification criteria as outlined on the delineation of clinical privileges form.

Laser Safety Training Materials

• Columbia St. Mary's Laser Credentialing
• Laser Credentialing Test

Completed Laser Acknowledgement Statement forms and Tests can be emailed to Central Credentials at csmcred@columbia-stmarys.org or faxed to 414.326.1728

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Because sedation-to-anesthesia is a continuum, it is not always possible to predict how an individual receiving medication with the intent to achieve Moderate Sedation will respond.  Individuals administering Moderate Sedation must be qualified and have the appropriate credentials to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.  To demonstrate competency and knowledge of hospital policy and procedure, providers requesting Moderate Sedation privileges must review the Moderate Sedation training materials and successfully complete the post-test.

Moderate Sedation Education Materials for Procedures, Excluding Intubation:

Moderate Sedation Packet and Test

Moderate Sedation with Intubation for Sedation with Intubation:

Sedation with Intubation Training

Sedation with Intubation Test

Completed Sedation privilege requests and tests can be emailed to Central Credentials at csmcred@columbia-stmarys.org or faxed to 414.326.1728.  Should you have additional questions, please call us at (414) 326-1895.

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