9 A8_HL_App

Part 3: Heart/Lung Transplant Program

PART 3A - Personnel – Transplant Program Director(s)

1. 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	Required Supporting Documents
	3A 1	Current C.V.

Name	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	Required Supporting Documents
	3B 1a	Current C.V.
	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.
	3B 1f	Formal Training: A letter from training director verifying that the fellow has met the requirements
	3B 1f	Formal Training: A log (organized by date) of the transplant and procurement procedures.
	3B 1g	Transplant Experience: A letter from program director verifying that the individual has met the requirements
	3B 1g	Transplant Experience: A log (organized by date) of the transplant and procurement procedures.
		Other Letters of Recommendation (Reference)
	4a	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.

a) Name: _____________________________________________________

b) Date of employment at this hospital (MM/DD/YY): ___________

Date assumed role of primary surgeon (MM/DD/YY): ___________

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.

3. Percentage of professional time spent at this hospital: _______% = _____ hrs/week

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

Facility	Type	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	Certificate Effective Date (MM/DD/YY)	Certificate Valid through Date (MM/DD/YY)	Certification Number

f) Transplant Training: List the name of the transplant hospital(s) at which heart/lung, heart, and/or lung transplant training (residency/fellowship) was received. Iinclude the program director(s) names, applicable dates, and the number of transplants and procurements performed. If the surgeon is qualifying as the primary surgeon through residency or fellowship training, also submit the supporting documents listed below. Refer to the Bylaws for the necessary qualifications and detailed descriptions of the required supporting documents:

• A letter from program director verifying that the fellow has met the requirements.

• Logs (Tables 4A and 4B) of the transplant and procurement procedures. The logs 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). Each log must be signed by the director of the training program.

Date From – To MM/DD/YY	Transplant Hospital	Program Director	# of Transplants as Primary Surgeon			# of Transplants as 1st Assistant			# of Procurements as Primary Surgeon or 1st Assistant
			HR	HL	LU	HR	HL	LU	HR	HL	LU
Residency:
Fellowship:

g) Transplant Experience (Post fellowship):

List the name of the transplant hospital(s), applicable dates, and number of heart/lung, heart, and/or lung transplants and procurements performed by the individual at each hospital. 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.

• Logs (Tables 4A and 4B) of the transplant and procurement procedures. Each 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).

Each 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	Transplant Hospital	Program Director	# of Transplants as Primary Surgeon			# of Transplants as 1st Assistant			# of Procurements as Primary Surgeon or 1st Assistant
			HR	HL	LU	HR	HL	LU	HR	HL	LU

h) Summarize how the surgeon's experience fulfills the membership criteria.

(Check all that apply)

Membership Criteria	Yes
1. On site
2. Certified by the American Board of Thoracic Surgery or the foreign equivalent
3. Thoracic Surgery Boards pending
4. Cardiothoracic Surgery Residency (may qualify via either heart or lung transplant training)
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplants
b. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurements
c. Primary surgeon or 1st assistant on 15 or more lung and/or heart/lung transplants
d. Primary surgeon or 1st assistant on 10 or more lung procurements
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 (may qualify via either heart or lung transplant training)
a. Primary surgeon or 1st assistant on 20 or more heart and/or heart/lung transplants
b. Primary surgeon or 1st assistant on 10 or more heart or heart/lung procurements
c. Primary surgeon or 1st assistant on 15 or more lung and/or heart/lung transplants
d. Primary surgeon or 1st assistant on 10 or more lung procurements
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) (may qualify via either heart or lung transplant experience)
a. Primary surgeon or 1st assistant 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 1st assistant on 10 or more heart or heart/lung procurements
c. Primary surgeon or 1st assistant on 15 or more lung and/or heart/lung transplants over a minimum of 2 years and a maximum of 5 years. Of these 15, at least 10 were performed as primary surgeon.
d. Primary surgeon or 1st assistant on 10 or more lung procurements
e. Involved in all levels of pre-, peri-, and post-operative patient care within the last 2 years
7. Pediatric Pathway (may qualify via either heart or lung transplant training/experience)
a. Program serves predominantly pediatric patients
b. Individual has maintained current working knowledge in all aspects of heart transplantation and patient care within the last 2 years.
c. Individual has maintained current working knowledge in all aspects of lung transplantation and patient care within the last 2 years.
d. Hospital has petitioned the Membership and Professional Standards Committee (MPSC) for approval
e. A preliminary interview before the Membership and Professional Standards Committee shall be required

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 hospitals. (Expand rows below as necessary and use complete sentences (i.e. narrative descriptions) for each).

	Describe 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 Pulmonary 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 Hospitals (if applicable)
Additional Information:

j) Describe the proposed primary surgeon's transplant training and experience in the areas listed below. (Expand rows below as necessary and use complete sentences (i.e. narrative descriptions) for each).

	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 Pulmonary 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:

PART 3B, Section 2: Personnel – Additional/Other Surgeons

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. All surgeons must be listed in Table 1 (Certificate of Investigation) in this application.

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.

PART 3B, Section 2: Personnel – Additional/Other Surgeons

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

Check list	Question Reference	Required Supporting Documents
	3B 2a	Current C.V.
	3B 2b	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.
	3B 2c,e,f	A letter from the Surgeon detailing his/her commitment to the program and level of involvement in substantive patient care.

1. Name: _____________________________________________________________

For heart/lung transplantation this individual is classified as ____ Additional Surgeon ___ Other Surgeon

(Check only one)

2. Date of employment at this hospital (MM/DD/YY): ____________

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.

3. 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	Certificate Effective Date (MM/DD/YY)	Certificate Valid through Date (MM/DD/YY)	Certification Number

e) Transpalnt Training (Residency/Fellowship): List the name of the transplant hospital(s) at which heart/lung, heart, and/or lung transplant training (residency/fellowship) was received. Include the program director(s) names, applicable dates, and the number of transplants and procurements the individual performed.

Date From – To MM/DD/YY

Transplant Hospital

Program Director

# of Transplants as Primary Surgeon

# of Transplants as 1st Assistant

# Procurements as Primary Surgeon or 1st Assistant

HR

HL

LU

HR

HL

LU

HR

HL

LU

Residency:

Fellowship:

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

Date From – To MM/DD/YY

Transplant Hospital

Program Director

# of Transplants as Primary Surgeon

# of Transplants as 1st Assistant

# Procurements as Primary Surgeon or 1st Assistant

HR

HL

LU

HR

HL

LU

HR

HL

LU

g) Describe the surgeon's level of involvement in this transplant program in the areas listed below. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	Describe 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 Pulmonary 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:

h) Describe the surgeon's transplant training and experience in the areas listed below. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	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 Pulmonary 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:

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	Required Supporting Documents
	3C 1a	Current C.V.
	3C 1b	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.
	3C 1c,f,g	Letter from the Physician detailing his/her commitment to the program; level of involvement with substantive patient care; and summarizing their previous transplant experience.
	3C 1f	Formal Training: A letter from training director verifying that the fellow has met the requirements
	3C 1f	Formal Training: Log(s) (organized by date of transplant) of the transplant patients followed.
	3C 1g	Transplant Experience: A letter from program director verifying that the individual has met the requirements
	3C 1g	Transplant Experience: Log(s) (organized by date of transplant) of the transplant patients followed.
	3C	Other Letters of Recommendation (Reference)
	4a	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:______________________________________________________________

Date of employment at this hospital (MM/DD/YY): ________________

Date assumed role of primary physician (MM/DD/YY): _____________

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	Type	Location (City, State)	% Professional Time Spent on Site

5. 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	Certificate Effective Date (MM/DD/YY)	Certificate Valid through Date (MM/DD/YY)	Certification Number

f) Transplant Training (Fellowship): List the program(s) at which heart/lung, heart, and/or lung transplant training was received. Iinclude the name of the transplant hospital(s), program director(s) names, applicable dates, and the number of transplant patients for whom the physician provided substantive patient care (pre-, peri- and post-operatively from the time of transplant). If the physician is qualifying as the primary physician through fellowship training, also submit the supporting documents listed below. Refer to the Bylaws for the necessary qualifications and descriptions of the required supporting documents.

• Letters from the director of fellowship training program and the supervising physician verifying that the fellow has met the requirements.

• A recipient log (Table 4C) that includes the date of transplant and the patient’s medical record and/or OPTN ID number. Each 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	Transplant Hospital	Program Director	# Heart Patients Followed			# Heart/Lung Patients Followed			# Lung Patients Followed
			Pre	Peri	Post	Pre	Peri	Post	Pre	Peri	Post

g) Transplant Experience (Post fellowship only): List the name of the transplant hospital(s), applicable dates, and number of heart/lung, heart and/or lung transplant patients 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 (Table 4C) that includes the date of transplant and the patient’s medical record and/or OPTN ID number. Each 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	Transplant Hospital	Program Director	# Heart Patients Followed			# Heart/Lung Patients Followed			# Lung Patients Followed
			Pre	Peri	Post	Pre	Peri	Post	Pre	Peri	Post

h) Training/Experience. Describe how the physician fulfills the criteria for participating as an observer in 3 multiple organ procurements and 3 transplants that include the heart or heart/lung, 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. Alternatively, describe how the physician fulfills the criteria 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 (Table 4D) of these cases that includes the date of procurement/transplant, medical record ID number and/or OPTN ID number, and the location of the donor.

• If these criteria have not been met, submit a plan explaining how the individual will fulfill them.

Date From To mm/dd/yy

Transplant Hospital

# Procurements Observed

#Transplants Observed

Observe Eval. of Donors/Donor Process

# of Multi-Organ Donors Observed Mgmt

HR

HL

LU

HR

HL

LU

HR

HL

LU

1. Summarize how the Transplant Physician's experience fulfills the membership criteria.

(Check all that apply)

Membership Criteria	Yes
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 foreign equivalent in Cardiology
b. Achieved eligibility in Cardiology
c. Certified by the American Board of Internal Medicine, Pediatrics or the foreign equivalent in Pulmonary Medicine
d. 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. Involved in the primary care of a minimum of 20 heart and/or heart/lung recipients from the time of transplant
b. Experience with pre-, peri-, and post-operative care within the last 2 years
c. Observed 3 procurements and 3 heart transplants
d. 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. Involved in the primary care of a minimum of 20 heart and/or heart/lung recipients from the time of transplant
b. Experience with pre-, peri-, and post-operative care within the last 2 years
c. Observed 3 procurements and 3 heart transplants
d. 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 heart-lung transplantation
a. 2-5 years experience on an active heart transplant service
b. Involved in the primary care of a minimum of 20 heart and/or heart/lung recipients for a minimum of 3 months from the time of their transplant
c. Experience with pre-, peri, and post-operative care within the last 2 years
d. Observed 3 procurements 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 primary care of 15 or more lung and/or heart/lung transplant recipients for a minimum of 3 months from the time of their transplant
b. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care within the last 2 years
c. Training program certified by the ABIM and/or the American Board of Pediatrics
d. Observed 3 or more lung or heart/lung procurements and transplants
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 primary care of 15 or more lung and/or heart/lung transplant recipients for a minimum of 3 months from the time of transplant
b. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care within the last 2 years
c. Training program certified by the ABIM and/or the American Board of Pediatrics
d. Observed 3 or more lung or heart/lung procurements and transplants
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
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 recipients for a minimum of 3 months from the time of their transplant
c. Involved with all aspects of pre-, peri-, and post-operative lung transplant patient care within the last 2 years
d. Observed 3 or more lung or heart/lung procurements and transplants
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. Individual has maintained current working knowledge in all aspects of heart and/or lung transplantation and patient care within the last 2 years.
c. Hospital has petitioned the Membership and Professional Standards Committee (MPSC) for approval
d. A preliminary interview before the Membership and Professional Standards Committee shall be required
12. 12-Month Conditional Pathway (Heart) – Only available to Existing Programs
a. Board certified cardiologist
b. Qualifying by virtue of training
i. Involved in the primary care of 10 or more heart or heart/lung transplant recipients from the time of their transplant
ii. Training hospital conducts 20 or more heart or heart/lung transplants per year
c. Qualifying by virtue of acquired clinical experience
i. Involved in the primary care of 10 or more heart or heart/lung transplant recipients for a minimum of 3 months from the time of their transplant
ii. Acquired a minimum of 12 months experience on an active heart transplant service over a maximum of 2 years
d. Consulting relationship established with counterparts at another UNOS member transplant hospital approved for heart transplantation (include letter of support).
13. 12-Month Conditional Pathway (Lung) - Only available to Existing Programs
a. Board certified pulmonologist
b. Participated in the primary care of 8 or more lung and/or heart/lung transplant recipients for a minimum of 3 months from the time of their transplant. At least one-half of these patients must be single and/or double lung transplant recipients
c. If qualifying by virtue of acquired clinical experience, this experience must be equal to 12 months on an active lung transplant service acquired over a maximum of 2 years.
d. A consulting relationship with counterparts at another UNOS member transplant hospital approved for lung transplantation has been established (include letter of support)

j) 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 hospitals. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	Describe Involvement
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 Pulmonary Care
Histologic interpretation and grading of lung biopsies for rejection
Coverage of Multiple Transplant Hospitals (if applicable)
Additional Information

k) Describe the proposed primary physician's transplant training and experience in the areas listed below. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	DescribeTraining/Experience
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 Pulmonary Care
Histologic interpretation and grading of lung biopsies for rejection
Additional Information

PART 3C, Section 2: Personnel – Additional/Other Physicians

Complete this section of the application to describe the involvement, training, and experience of additional/other physicians associated with the program. Physicians must be designated as Additional or Other as described below.

All physicians must be listed in Table 1 (Certificate of Investigation) in this application.

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.

PART 3C, Section 2: Personnel – Additional/Other Physicians

2. Additional/Other Physicians (Duplicate this section 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.
	3C 2c,e,f	A letter from the Physician detailing his/her commitment to the program and level of involvement in substantive patient care.

a) Name: _____________________________________________________

For heart/lung transplantation this individual is classified as ____ Additional Physician ___ Other Physician

(Check only one)

Date of employment at this hospital (MM/DD/YY): ____________________

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	Certificate Effective Date (MM/DD/YY)	Certificate Valid through Date (MM/DD/YY)	Certification Number

5. Training (Fellowship): List the program(s) at which heart/lung, heart and/or lung transplant training was received. Include the name of the transplant hospital(s), program director(s) names, applicable dates, and the number of transplant patients followed for whom the physician provided substantive care (pre-, peri- and post-operatively from the time of transplant).

Date From To mm/dd/yy	Transplant Hospital	Program Director	# Heart Patients Followed			# Heart/Lung Patients Followed			# Lung Patients Followed
			Pre	Peri	Post	Pre	Peri	Post	Pre	Peri	Post

6. Transplant Experience (Post fellowship only): List the name of the transplant hospital(s), applicable dates, and the number of heart/lung, heart and/or lung patients 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	Transplant Hospital	Program Director	# Heart Patients Followed			# Heart/Lung Patients Followed			# Lung Patients Followed
			Pre	Peri	Post	Pre	Peri	Post	Pre	Peri	Post

g) Describe in detail the transplant physician’s involvement in this heart/lung transplant program. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	Describe Involvement
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 Pulmonary Care
Histologic interpretation and grading of lung biopsies for rejection
Additional Information

8. Describe the physician’s transplant training and experience in the role of transplant patient management in the areas listed below. (Expand rows as necessary and use complete sentences (i.e. narrative descriptions) for each).

	Describe Training/Experience
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 Pulmonary Care
Histologic interpretation and grading of lung biopsies for rejection
Additional Information

Table 1: Certificate of Investigation

List all transplant surgeons and physicians currently involved in this program.

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*

2. 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) If yes, what steps are being 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.

Table 2 - Program Coverage Plan

Please answer the questions below and provide a written copy of the current Program Coverage Plan. The plan must be signed by either:

a. the OPTN/UNOS Representative;

b. the Program Director(s); or

c. the Primary Surgeon and Primary Physician.

In accordance with the Bylaws, the program director, in conjunction with the primary transplant surgeon and transplant physician, must submit to UNOS a written Program Coverage Plan, which documents how 100% medical and surgical coverage is provided by individuals credentialed by the transplant hospital to provide transplant service for the program. A transplant program served by a single surgeon or physician shall inform its patients of this fact and potential unavailability of one or both of these individuals, as applicable, during the year. The Program Coverage Plan must address the following requirements:

	Yes	No
Is this a single surgeon program?
Is this a single physician program?
If the answer to either one of the above questions is “Yes,” explain the protocol for notifying patients.
Does this transplant program have transplant surgeon(s) and physician(s) available 365 days a year, 24 hours a day, 7 days a week to provide program coverage?
If the answer to the above question is “No”, an explanation must be provided that justifies why the current level of coverage should be acceptable to the MPSC.
Transplant programs shall provide patients with a written summary of the Program Coverage Plan at the time of listing and when there are any substantial changes in program or personnel. Has this program developed a plan for notification?
Is a surgeon/physician available and able to be on the hospital premises within one-hour ground transportation time to address urgent patient issues?
Is a transplant surgeon readily available in a timely manner to facilitate organ acceptance, procurement, and implantation?
Unless exempted by the MPSC for specific causal reasons, the primary transplant surgeon/primary transplant physician cannot be designated as the primary surgeon/primary transplant physician at more than one transplant hospital unless there are additional transplant surgeons/transplant physicians at each of those facilities. Is this program requesting an exemption? If yes, provide explanation below.
Additional information:

Table 3: OPTN Staffing Report

HEART/LUNG TRANSPLANT PROGRAM

Member Code:	Name of Transplant Hospital:
Main Program Phone Number	Main Program Fax Number:	Hospital URL: http://www
Toll Free Phone numbers for Patients: Hospital #: Program #:

Answer the questions below for this transplant program. Since this information will be used to update UNet^sm and the Membership Directory, make sure to include the best (most accurate) telephone number and address for each person. Use additional pages as necessary. The surgeons and physicians named below should match those listed on the Certificate of Investigation.

Identify the Transplant Program Medical and/or Surgical Director(s):

Name	Address	Phone	Fax	Email

The surgeons who perform transplantsare:

Name	Additional	Other	Address	Phone	Fax	Email

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

Name	Additional	Other	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 is listed.

Name	Address	Phone	Fax	Email

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

Name	Address	Phone	Fax	Email

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

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

Name	Address	Phone	Fax	Email

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

Name	Address	Phone	Fax	Email

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

Name	Address	Phone	Fax	Email

Table 4A Primary Surgeon - Transplant Log (Sample)

Complete a separate form for each transplant hospital

Organ:
Name of Proposed Primary Surgeon:
Name of transplant hospital where transplants were performed:
Date range of surgeon’s appointment/training: MM/DD/YY to MM/DD/YY

List cases in date order

#	Date of Transplant	Medical Record/ OPTN ID #	Primary Surgeon	1st Assistant
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

Extend lines on log as needed

Patient ID should not be name or Social Security Number.

Director’s Signature: ____________________________________________ Date: ___________________

Table 4B - Primary Surgeon - Procurement Log (Sample)

Complete separate form for each transplant center

Organ:
Name of Proposed Primary Surgeon:
Name of transplant hospital where surgeon was employed when procurements were performed:
Date range of surgeon’s appointment/training: MM/DD/YY to MM/DD/YY

List cases in date order

#	Date of Procurement	Medical Record/ OPTN ID # of Donor	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: ____________________________________________ Date: ___________________

Table 4C - Primary Physician – Recipient Log (Sample)

Complete separate form for each transplant hospital

Organ:
Name of Proposed Primary Physician:
Name of transplant hospital where transplants were performed:
Date range of physician’s appointment/training: MM/DD/YY to MM/DD/YY

List cases in date order.

List only those patients followed for 3 months from the time of transplant (including pre-, peri-, and post-operative management)

#	Date of Transplant	Medical Record/ OPTN ID #	Pre-Operative	Peri-Operative	Post-Operative (90-days follow-up care)	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

Extend lines on log as needed

Director’s Signature: ____________________________________________ Date: ___________________

Table 4D - Primary Physician – Observation Log (Sample)

Organ:
Name of Proposed Primary Physician
Name of hospital where physician was employed when observations were performed
Date range of physician’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 (Transplant Hospital)
1
2
3
4
5

Donor Selection and Management

#	Date of Procurement	Medical Record/ OPTN ID #	Location of Donor (Hospital)	Heart/Lung, Lung, Heart, or or Multi-organ?
1
2
3
4
5

11/30/10 Version Heart/Lung - 1