0

Heart/Lung Transplant Program
PART 3A 1.

Personnel – Transplant Program Director(s)

Identify the Transplant Program Surgical and/or Medical Director(s) of the heart/lung transplant program (include
C.V.). Briefly describe the leadership responsibilities for each.
Check
list

Question
Reference
3A 1

Name

Required Supporting Documents
Current C.V.

Date of
Appointment

Primary areas of responsibility

PART 3B, Section 1: Personnel – Surgical – Primary Surgeon
1.

Primary Heart/Lung Transplant Surgeon. Refer to the Bylaws for the necessary qualifications and more specific
descriptions of the required supporting documents listed below.
Check
list

Question
Reference
3B 1a
3B 1b

Letter from the Credentialing Committee of the applicant hospital stating that the surgeon meets all
requirements to be in good standing. Please provide an explanation of any status other than active/full

3B 1c,g,h

Letter from the Surgeon detailing his/her commitment to the program and describing their transplant
experience/training.
Formal Training: A letter from training director verifying that the fellow has met the requirements
Formal Training: A log (See Tables 1 & 2) of the transplant and procurement procedures.
Transplant Experience: A letter from program director verifying that the fellow has met the
requirements
Transplant Experience: A log (See Tables 1 & 2) of the transplant and procurement procedures.
Other Letters of Recommendation (Reference)
Letter of recommendation attesting to the individual’s overall qualifications to act as primary surgeon
and addressing the individual’s personal integrity, honesty, familiarity with and experience in
adhering to OPTN requirements and compliance protocols, and other matters as deemed appropriate.

3B 1f
3B 1f
3B 1g
3B 1g
4a

a)

Required Supporting Documents
Current C.V.

Name: _____________________________________________________

b) Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
_____
Yes
Provide copy of hospital credentialing letter.
_____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.
c)

Version date pending

Percentage of professional time spent at this facility: _______% = _____ hrs/week

Heart/Lung - 1

d) List below the hospitals, health care facilities, and medical group practices and percentage of professional
time this individual is on site at each:

Facility

e)

Type

% Professional
time Spent on site

Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has
been scheduled. If individual has been recertified, please use that date.

Certification Type

Version date pending

Location (city, state)

Heart/Lung - 2

Effective Date
(MM/DD/YY)

Certification Number

f)

Formal Training: List the name of the institution(s) in which heart/lung, heart, and/or lung transplant training (residency/fellowship) was received
including Program Director(s) names, applicable dates, and the number of transplant procedures performed. Refer to the Bylaws for the necessary
qualifications and descriptions of the required supporting documents listed below unless the individual meets the pathway for post fellowship
experience as described in the requirements:
•
•

A letter from program director verifying that the fellow has met the requirements.
A log (See Tables 1 & 2) of the transplant and procurement procedures. The log should include a patient identifier/OPTN ID Number, transplant/procurement
date and the surgeon’s role in the procedure (i.e., primary or 1st assistant). These logs must be signed by the director of the training program.

Date
From To
mm/dd/yy
Residency:
_______ to
_______

Institution

Program Director

# TX as Primary
Surgeon
HR
HL
LU

# TX as First
Assistant
HR
HL
LU

# Procurements as
Primary or First
Assistant
HR
HL
LU

Fellowship
_______ to
_______

g) Transplant Experience (Post fellowship):
List the name of the institution(s), applicable dates, and number of heart/lung, heart, and/or lung transplants performed by the individual at each institution.
Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below.
•
•

Letter(s) of reference from the program director(s) listed below.
A log (See Tables 1 & 2) of the transplant and procurements procedures. The log should include a patient identifier/OPTN ID Number, transplant/procurement date
and the surgeon’s role in the procedure (i.e., primary or 1st assistant).
The transplant log(s) should be signed by the program director, division chief, or department chair from the program where the experience was gained.

Date
From To
mm/dd/yy

Version date pending

Institution

Heart/Lung - 3

Program
Director

# TX as Primary
Surgeon
HR
HL
LU

# TX as First
Assistant
HR
HL
LU

# Procurements as
Primary or First
Assistant
HR
HL
LU

h) Summarize how the surgeon's experience fulfills the membership criteria.
(Check all that apply)
Membership Criteria
On site
Certified by the American Board of Thoracic Surgery or the equivalent
Thoracic Surgery Boards pending
Cardiothoracic Surgery Residency
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplant
procedures
b. Primary surgeon or 1st assistant on 15 or more lung and/or heart/lung transplant
procedures
c. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurement
procedures
d. Primary surgeon or 1st assistant on 10 or more lung procurement procedures
e. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2
years
f. Training program approved by American Board of Thoracic Surgery
5. 12-month Transplant Fellowship
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplant
procedures
b. Primary surgeon or 1st assistant on 15 or more lung and/or heart/lung transplant
procedures
c. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurement
procedures
d. Primary surgeon or 1st assistant on 10 or more lung procurement procedures
e. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2
years
f. Training program approved by American Board of Thoracic Surgery
6. Experience (Post Fellowship)
a. Primary surgeon or first assist on 20 or more heart and/or heart/lung transplants over a
minimum of 2 years and a maximum of 5 years. Of these 20, at least 15 were
performed as primary surgeon.
b. Primary surgeon or first assist on 15 or more lung and/or heart/lung transplant
procedures over a minimum of 2 years and a maximum of 5 years. Of these 15, at least
10 were performed as primary surgeon.
c. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurement
procedures
d. Performed 10 or more lung procurement procedures
e. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2
years
7. Pediatric Pathway
a. Program serves predominantly Pediatric Patients
b. Demonstrate that the individual has maintained current working knowledge in all
aspects heart transplantation and patient care within the last 2 years.
c. Demonstrate that the individual has maintained current working knowledge in all
aspects lung transplantation and patient care within the last 2 years.
d. Petition the MPSC for approval
e. A preliminary interview before the Committee shall be required
1.
2.
3.
4.

Version date pending

Heart/Lung - 4

Yes

i)

Describe in detail the proposed primary surgeon's level of involvement in this transplant program, and if
applicable, describe the surgeon's plan for coverage of transplant programs located in multiple transplant
centers. (Expand rows below as necessary).
Describe Level of Involvement
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Use of Mechanical Assist
Devices
Care of Acute and Chronic
Lung Failure
Cardiopulmonary Bypass
Pre- and Postoperative
Ventilator Care
Histologic Interpretation
and Grading of Lung
Biopsies for Rejection
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Long-term Outpatient
Follow-up
Coverage of Multiple
Transplant Centers (if
applicable)
Additional Information:

Version date pending

Heart/Lung - 5

j)

Describe the proposed primary surgeon's transplant training and experience in the areas listed below. (Expand
rows below as necessary).
Describe Experience /Training
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Use of Mechanical Assist
Devices
Care of Acute and Chronic
Lung Failure
Cardiopulmonary Bypass
Pre- and Postoperative
Ventilator Care
Histologic Interpretation
and Grading of Lung
Biopsies for Rejection
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Long-term Outpatient
Follow-up
Additional Information:

Version date pending

Heart/Lung - 6

Additional Instructions for PART 3B, Section 2: Personnel – Surgical
Complete this section of the application to describe the involvement, training, and experience of any other
surgeons participating in the program. Surgeons must be designated as Additional or Other as described
below.
The Bylaws provide the following definition of Additional Transplant Surgeon:
Additional Transplant Surgeons must be credentialed by the institution to provide transplant services and be
able to independently manage the care of transplant patients including performing the transplant operation
and procurement procedures.
Surgeons that also support this program but who do not meet the definition of “primary” or additional,” should
complete this section as well. The type should be indicated as “other.”
Duplicate pages as needed.

Version date pending

Heart/Lung - 7

PART 3B, Section 2: Personnel – Surgical
2.

List Additional/Other Surgeons (duplicate this page as needed). Provide the attachments listed below:
Check
list

Question
Reference
3B 2a
3B 2b

3B 2c,e,f

a)

Required Supporting Documents
Current C.V.
A letter from the Credentialing Committee of the applicant hospital stating that
the surgeon meets all requirements to be in good standing. Please provide an
explanation of any status other than active/full.
A letter from the Surgeon detailing his/her commitment to the program and level
of involvement in substantive patient care.

Name: _____________________________________________________________
For heart/lung transplantation this individual is classified as ____ Additional Surgeon
(Check only one)

b) Date of appointment (MM/DD/YY) at this Facility: ____________

___ other Surgeon

To this position: _________

Does individual have FULL privileges at this hospital?
_____
Yes
Provide copy of hospital credentialing letter.
_____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.

c)

Percentage of professional time spent on site: _______% = _____ hrs/week

d) Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has been
scheduled. If individual has been recertified, please use that date.

Certification Type

Version date pending

Heart/Lung - 8

Effective Date
(MM/DD/YY)

Certification
Number

e) Training (Residency/Fellowship): List the name of the institution(s) in which heart/lung, heart, and/or lung transplant training (fellowship) was received including
Program Director(s) names, applicable dates, and the number of transplants the individual performed.

Date
From To
mm/dd/yy
Residency:
_______ to
_______

Institution

Program Director

# TX as Primary
Surgeon
HR
HL
LU

# TX as First
Assistant
HR
HL
LU

# Procurements as
Primary or First
Assistant
HR
HL
LU

Fellowship
_______ to
_______

f)

Transplant Experience (Post fellowship): List the name of the institution(s), applicable dates, and number of heart/lung, heart and/or lung transplants performed by
the individual at each institution.

Date
From To
mm/dd/yy

Version date pending

Institution

Heart/Lung - 9

Program Director

# TX as Primary
Surgeon
HR
HL
LU

# TX as First
Assistant
HR
HL
LU

# Procurements as
Primary or First
Assistant
HR
HL
LU

g) Describe the surgeon's level of involvement in this heart transplant program in the areas listed below. (Expand rows
as necessary)
Describe Level of Involvement
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Use of Mechanical Assist
Devices
Care of Acute and Chronic
Lung Failure
Cardiopulmonary Bypass
Pre- and Postoperative
Ventilator Care
Histologic Interpretation
and Grading of Lung
Biopsies for Rejection
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Long-term Outpatient
Follow-up
Additional Information:

Version date pending

Heart/Lung - 10

h) Describe the surgeon's heart transplant training and experience in the areas listed below. (Expand rows as necessary)
Describe Experience /Training
Pre-Operative Patient
Management
Recipient Selection
Donor Selection
Transplant Surgery
Use of Mechanical Assist
Devices
Care of Acute and Chronic
Lung Failure
Cardiopulmonary Bypass
Pre- and Postoperative
Ventilator Care
Histologic Interpretation
and Grading of Lung
Biopsies for Rejection
Post-Operative
Hemodynamic Care
Post-Operative
Immunosuppressive
Therapy
Long-term Outpatient
Follow-up
Additional Information:

Version date pending

Heart/Lung - 11

PART 3C, Section 1: Personnel – Medical – Primary Physician
1.

Primary Heart/Lung Transplant Physician. Refer to the Bylaws for necessary qualifications. Provide the
attachments listed below:
Check
list

Question
Reference
3C 1a
3C 1b
3C 1c,f,g
3C 1f
3C 1f
3C 1g
3C 1g
3C

4a

Required Supporting Documents
Current C.V.
Letter from the Credentialing Committee of the applicant hospital stating that the physician meets
all requirements to be in good standing. Please provide an explanation of any status other than
active/full.
Letter from the Physician detailing his/her commitment to the program; level of involvement with
substantive patient care; and summarizing their previous transplant experience.
Formal Training: A letter from training director verifying that the fellow has met the requirements
Formal Training: A log (See Table 3) of the transplant patients followed.
Transplant Experience: A letter from program director verifying that the fellow has met the
requirements
Transplant Experience: A log (See Table 3) of the transplant patients followed.
Other Letters of Recommendation (Reference)
Letter of recommendation attesting to the individual’s overall qualifications to act as primary
physician and addressing the individual’s personal integrity, honesty, familiarity with and
experience in adhering to OPTN requirements and compliance protocols, and other matters as
deemed appropriate

a) Name:______________________________________________________________
b) Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
_____
Yes
Provide copy of hospital credentialing letter.
_____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.
c)

Percentage of professional time on site: _______% = _____ hrs/week

d) List other hospitals, health care facilities, and medical group practices and percentage of professional time
on site at each:

Facility

Version date pending

Type

Heart/Lung - 12

Location (city, state)

% Professional
time Spent on
site

e)

Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has
been scheduled. If individual has been recertified, please use that date.

Certification Type

Version date pending

Heart/Lung - 13

Effective Date
(MM/DD/YY)

Certification
Number

f)

Training (Fellowship): List the program(s) in which heart/lung, heart, and/or lung transplant training was received including name of institution(s), Program Director(s)
names, applicable dates, and the number of transplant patients for which the physician provided substantive patient care (pre-, peri- and post-operatively from the time of
transplant). Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below unless the individual meets the pathway
for post fellowship experience as described in the requirements.
•
•

Letters from the Director of fellowship training program and the supervising physician verifying that the fellow has met the requirements.
A recipient log (See Table 3) that includes the date of transplant, the patient’s medical record and/or OPTN ID number. This log must be signed by the director of the training
program and/or primary transplant physician at that transplant program.

Date
From To
mm/dd/yy

Institution

Program Director

# HEART
Patients Followed:
Pre
Peri
Post

# HEART/LUNG
Patients Followed:
Pre
Peri
Post

#LUNG
Patients Followed:
Pre
Peri
Post

g) Experience (Post fellowship only): List the name of the institution(s) and applicable dates, number of heart/lung, heart and/or lung transplants performed at the institution
for whom the Transplant Physician accepted primary responsibility for substantive patient care (pre-, peri-, and post-operatively from the time of transplant). Refer to the
Bylaws for the necessary qualifications and descriptions of the required supporting documents listed below.
•
•

Two supporting letters - at least one must be from the heart/lung transplant surgeon with whom the physician has previously worked.
A recipient log (See Table 3) that includes the date of transplant, the patient’s name and/or OPTN ID number. This log should be signed by the program director, division chief,
or department chair from the program where the experience was gained.

Date
From To
mm/dd/yy

Version date pending

Institution

Program Director

Heart/Lung - 14

# HEART
Patients Followed:
Pre
Peri
Post

# HEART/LUNG
Patients Followed:
Pre
Peri
Post

#LUNG
Patients Followed:
Pre
Peri
Post

Version date pending

Heart/Lung - 15

h) Training/Experience. Describe how the physician fulfills the requirements for participation as 1) an observer in 3 multiple organ procurements and 3 transplants that
include the heart, as well as observing the evaluation of the donor and donor process, and management of at least 3 multiple organ donors which include the heart
and/or heart/lung; or 2) Alternatively, describe how the physician fulfills the requirements for participation as an observer in 3 or more lung or heart/lung procurement
procedures and subsequent transplants, as well as observing the selection and management of at least 3 multiple organ donors, which include the lung or heart/lung.
•
•

Provide a log (See Table 4) of these cases that includes the date of procurement, medical record ID number and/or OPTN ID number, and the location of the donor.
If these requirements have not been met, submit a plan explaining how the individual will fulfill them.

Date
From To
mm/dd/yy

Version date pending

Institution

Heart/Lung - 16

Program Director

# Procurements
Observed:
HR
HL
LU

Observe Eval. of
Donors/Donor
Process

#Transplants
Observed
HR

HL

LU

HR

HL

LU

# of MultiOrgan Donors
Observed
Mgmt

i)

Summarize how the Transplant Physician's experience fulfills the membership criteria for membership.
(Check all that apply)

Membership Criteria
1. On site
2. M.D., D.O. or equivalent degree
3. Board Certification
a. Certified by the American Board of Internal Medicine, Pediatrics or the equivalent
b. Board certified in Cardiology
c. Achieved eligibility in Cardiology
d. Board certified in Pulmonary Medicine
e. Achieved eligibility in Pulmonary Medicine
4. Direct involvement in heart, lung, and/or heart/lung transplant patient care within the last 2
years
5. Cardiology Fellowship
a.
b.
c.
d.

Minimum of 20 heart and/or heart/lung patients followed from the time of transplant
Experience with pre-, peri-, post-operative care within the last 2 years
Observed 3 procurement procedures and 3 heart transplants
Observed evaluation of the donor and donor process and management of at least 3
multiple organ donors that include the heart and or heart/lung
6. 12-month Transplant Cardiology Fellowship
a.
b.
c.
d.

Minimum of 20 heart and/or heart/lung patients followed from the time of transplant
Experience with pre-, peri-, and post-operative care within the last 2 years
Observed 3 procurement procedures and 3 heart transplants
Observed evaluation of the donor and donor process and management of at least 3
multiple organ donors that include the heart and or heart/lung
7. Experience in heart and/or heart-lung transplantation
a. 2-5 years experience on an active heart transplant service
b. Minimum of 20 heart and/or heart/lung patients followed for a minimum of 3 months
from the time of their transplant
c. Experience with pre-, peri, post-operative care within the last 2 years
d. Observed 3 procurement procedures and 3 heart transplants
e. Observed evaluation of the donor and donor process, and management of at least 3
multiple organ donors that include the heart and/or heart/lung
8. Pulmonary Medicine Fellowship
a. Participated in the care of 15 or more lung and/or heart/lung transplant patients from the
time of transplant
b. Observed 3 or more lung procurement procedures and transplants
c. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care
within the last 2 years
d. Training program certified by the ABIM and/or the American Board of Pediatrics
e. Observed evaluation of the donor and donor process, and management of at least 3
multiple organ donors that include the lung and/or heart/lung
9. 12-month Transplant Pulmonology Fellowship
a. Participated in the care of 15 or more lung and/or heart/lung transplant patients from the
time of transplant
b. Observed 3 or more lung procurement procedures and transplants
c. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care
within the last 2 years
d. Training program certified by the ABIM and/or the American Board of Pediatrics
e. Observed evaluation of the donor and donor process, and management of at least 3
multiple organ donors that include the lung and/or heart/lung
Version date pending
Heart/Lung - 17

Yes

Membership Criteria
10. Experience in lung and/or heart/lung transplantation (post-fellowship)
a. 2-5 years experience on an active lung transplant service
b. Participated in the primary care of 15 or more lung and/or heart/lung transplant patients
for a minimum of 3 months from the time of their transplant
c. Observed 3 or more lung procurement procedures and transplants
d. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care
within the last 2 years
e. Observed evaluation of the donor and donor process, and management of at least 3
multiple organ donors that include the lung and/or heart/lung
11. Pediatric Pathway
a. Program serves predominantly Pediatric Patients
b. Demonstrate that the individual has maintained current working knowledge in all aspects
heart transplantation and patient care within the last 2 years.
c. Petition the MPSC for approval
d. A preliminary interview before the Committee shall be required

j)

Yes

Describe in detail the proposed primary transplant physician's involvement in the management of patients in this
program and, if applicable, their plan for coverage of multiple transplant centers. (Expand rows as necessary).
Areas of Involvement in this program
Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart and/or Lung
Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic interpretation and grading of
myocardial biopsies for rejection
Care of Acute and Chronic Lung Failure
Cardiopulmonary Bypass
Pre- and Postoperative Ventilator Care
Coverage of Multiple Transplant Centers (if
applicable)
Additional Information

Version date pending

Heart/Lung - 18

Description

k) Describe the proposed primary physician's transplant training and experience in the areas listed below.
(Expand rows as necessary)
Experience and Training

Description of Individual’s current working
knowledge in the these areas

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart and/or Lung
Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic interpretation and grading of
myocardial biopsies for rejection
Cardiopulmonary Bypass
Pre- and Postoperative Ventilator Care
Additional Information

Version date pending

Heart/Lung - 19

Additional Instructions for PART 3C, Section 2: Personnel – Physicians
Complete this section of the application to describe the involvement, training, and experience of other physicians
associated with the program. Physicians must be designated as Additional or Other as described below.
The Bylaws provide the following definition of Additional Transplant Physician:
Additional Transplant Physicians must be credentialed by the institution to provide transplant services and be
able to independently manage the care of transplant patients.
Physicians that also support this program but who do not meet the definition of “primary” or “additional,” should
complete this section of the application. The type should be indicated as “other.”
Duplicate pages as needed

Version date pending

Heart/Lung - 20

PART 3C, Section 2: Personnel – Physicians
2.

Additional Physicians (Duplicate this page as needed). Refer to the Bylaws for the necessary qualifications and
descriptions of the required supporting documents listed below.
Check
list

Question
Reference

Required Supporting Documents

3C 2a

Current C.V.

3C 2b

A letter from the Credentialing Committee of the applicant hospital stating that the
physician meets all requirements to be in good standing. Please provide an
explanation of any status other than active/full.
A letter from the Physician detailing his/her commitment to the program and level
of involvement in substantive patient care.

3C 2c,e,f

a)

Name: _____________________________________________________
For heart/lung transplantation this individual is classified as ____ Additional Physician ___ other Physician
(Check only one)

b) Date of Appointment (MM/DD/YY): Facility: __________ To this position: ___________
Does individual have FULL privileges at this hospital?
_____
Yes
Provide copy of hospital credentialing letter.
_____
No
If the individual does not have full privileges, explain why and provide the date the
individual will be considered for full privileges. Include an explanation that
describes the scope of privileges.

c)

Percentage of professional time spent on site: _______% = _____ hrs/week

d) Board certification type (s) or equivalent. If board certification is pending, indicate the date the exam has been
scheduled. If individual has been recertified, please use that date.

Certification Type

Version date pending

Heart/Lung - 21

Effective Date
(MM/DD/YY)

Certification Number

e)

Training (Fellowship): List the program(s) in which heart/lung, heart and/or lung transplant training was received including name of institution(s), Program
Director(s) names, applicable dates, and the number of transplant patients followed for which the physician provided substantive care (pre-, peri- and postoperatively from the time of transplant).

Date
From To
mm/dd/yy

f)

Program Director

# HEART/LUNG
Patients Followed:
Pre
Peri
Post

#LUNG
Patients Followed:
Pre
Peri
Post

Transplant Experience (Post fellowship only): List the name of institution(s), applicable dates, and the number of heart/lung, heart and/or lung transplants
performed at the institution for whom the Transplant Physician accepted primary responsibility for substantive patient care (pre-, peri- and post-operatively from
the time of transplant).

Date
From To
mm/dd/yy

Version date pending

Institution

# HEART
Patients Followed:
Pre
Peri
Post

Institution

Heart/Lung - 22

Program Director

# HEART
Patients Followed:
Pre
Peri
Post

# HEART/LUNG
Patients Followed:
Pre
Peri
Post

#LUNG
Patients Followed:
Pre
Peri
Post

g) Describe in detail the transplant physician’s involvement in this heart/lung transplant program. (Expand rows
as necessary)
Areas of Involvement in this program
Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart and/or Lung
Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic interpretation and grading of
myocardial biopsies for rejection
Cardiopulmonary Bypass
Pre- and Postoperative Ventilator Care
Additional Information

Version date pending

Heart/Lung - 23

Description

h)

Describe the physician’s transplant training and experience in the role of transplant patient management in the
areas listed below. (Expand rows as necessary).
Experience and Training

Description of Individual’s current working
knowledge in the these areas

Candidate Evaluation Process
Pre- and Post-Operative Hemodynamic Care
Post-Operative Immunosuppressive Therapy
Long-term Outpatient Follow-up
Care of Acute and Chronic Heart and/or Lung
Failure
Use of Mechanical Assist Devices
Donor Selection
Recipient Selection
Histologic interpretation and grading of
myocardial biopsies for rejection
Cardiopulmonary Bypass
Pre- and Postoperative Ventilator Care
Additional Information

Version date pending

Heart/Lung - 24

PART 4: Certification of Investigation
The Bylaws state that “Each primary surgeon or primary physician, listed on the application as a part of the plan for
who shares coverage responsibility, shall submit an assessment, subject to medical peer review confidentiality
requirements and which follows guidelines provided in the application and is satisfactory to the MPSC, of all physicians
and surgeons participating in the program regarding their involvement in prior transgressions of UNOS requirements
and plans to ensure that the improper conduct is not continued.” (Emphasis Added)
a)

This hospital has conducted its own peer review of all surgeons and physicians listed below to ensure
compliance with applicable OPTN/UNOS Bylaws.

Names of Surgeons*

Names of Physicians*

b) If prior transgressions were identified has the hospital developed a plan to ensure that the improper conduct is not
continued?
____ Yes
___ No
___ Not Applicable

c) What steps will be/were taken to correct the prior improper conduct or to ensure the improper conduct is not
repeated in this program? Provide a copy of the plan.

I certify that this review was performed for each named surgeon and physician according to the hospital’s peer review
procedures.
Signature of Primary Surgeon:

Date:

Print name:
Signature of Primary Physician:

Date:

Print name:

* expand rows as needed.
Version date pending

Heart/Lung - 25

Part 5: OPTN Staffing Report
HEART/LUNG TRANSPLANT PROGRAM
Member Code:

Name of Hospital:

Main Program Phone Number

Main Program Fax Number:

Toll Free Phone numbers for Patients:

Hospital #:

Hospital URL: http://www
Program #:

Answer the questions below for this transplant program. Since this information will be used to update UNETsm and the Membership Directory, make sure to include the best (most
accurate) telephone number and address for each person. Use additional pages as necessary.
Identify the Transplant Program Medical and/or Surgical Director(s):
Name

Address

Phone

Fax

Email

Phone

Fax

Email

The surgeons who participate in this transplant program are:
Name

Version date pending

Address

Heart/Lung - 26

Version date pending

Heart/Lung - 27

The physicians (internists) who participate in this transplant program are:
Name

Address

Phone

Fax

Email

Identify the Hospital Administrative Director/Manager who will be involved with this program: Use an * to indicate which individual will serve as the primary Transplant
Administrator if more than one.
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Financial Counselor(s) who will be prominently involved with this program:
Name

Version date pending

Address

Heart/Lung - 28

The clinical transplant coordinators who participate in this transplant program are:
Name

Address

Phone

Fax

Email

List the data coordinators for this transplant program below. Use an * to indicate which individual will serve as the primary data coordinator.
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Social Worker(s) who will be prominently involved with this program:
Name

Version date pending

Address

Heart/Lung - 29

Identify the Pharmacist (s) who will be prominently involved with this program:
Name

Address

Phone

Fax

Email

Phone

Fax

Email

Identify the Director of Anesthesiology who will be prominently involved with this program:
Name

Version date pending

Address

Heart/Lung - 30

TABLE 1 – Primary Surgeon - Transplant Log (Sample)
Organ
Name of Proposed Primary Surgeon:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

Date of Transplant

PT ID

Primary Surgeon

1st Assistant

Director’s Signature: ____________________________________________
Extend lines on log as needed

Version date pending

Heart/Lung - 31

Date: ___________________

TABLE 2

Primary Surgeon - Procurement Log (Sample)

Organ
Name of Proposed Primary Surgeon:
Name of hospital where surgeons was employed
when procurements were performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#

Date of
Procurement

Donor ID
Number

Location of
Donor (hospital)

Comments
(LRD/CAD/Multi-organ)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
*extend lines on log as needed
Director’s Signature: ____________________________________________

Version date pending

Heart/Lung - 32

Date: ___________________

TABLE 3 – Primary Physician Log (1) (Sample)
List only those patients followed for 3 months from the time of transplant (including pre-, peri-, and postoperative management)
Organ
Name of Proposed Primary Physician:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
List cases listed in date order
#

Date of Transplant

PT ID

Comments

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Director’s Signature: ____________________________________________
Extend lines on log as needed
Version date pending

Heart/Lung - 33

Date: ___________________

TABLE 4 Primary Physician Log (2) (Sample)
(Header should include the following information. Cases should be listed in date order)

Organ
Name of Proposed Primary Physician:
Name of hospital where transplants were
performed:
Date range of surgeon’s appointment/training:
MM/DD/YY TO MM/DD/YY
In the tables below document how the physician fulfills the requirements for participation as an observer in organ
procurements and transplants, as well as observing the selection and management of at least 3 multiple organ donors that
include the organ for which application is being submitted. List cases in date order.
Procurements Observed
#

Date of
Procurement

Medical Record/
OPTN ID #

Location of Donor (Hospital)

1
2
3
4
5
Transplants Observed
#

Date of
Transplant

Medical Record/
OPTN ID #

Location (Hospital)

1
2
3
4
5
Donor Selection and Management
#

Date of
Procurement

Medical Record/
OPTN ID #

Location of Donor
(Hospital)

1
2
3
4
5

Version date pending

Heart/Lung - 34

Specify Organ specific
or Multi-organ?