5 Guidelines for Researching and Developing Privileging Content

The purpose of delineating clinical privileges is to manage what services a provider is qualified and authorized to deliver to a patient for that specific facility. Determining what constitutes the appropriate education, training, and experience is just one challenge. Others include answering the questions:

  • Who requires privileges (physicians, physician assistants, CRNAs, advanced practice professionals (APPs), or others) to provide the treatment/service?
  • What’s the best starting point in obtaining the right number of recent successful outcomes to gauge current competence? 
  • How will we evaluate the performance of the privilege?

There are numerous examples of high-profile cases where privileging information or decision errors resulted in patient harm, negligent credentialing lawsuits, and other undesired outcomes. However, the best defense for sound privileging from the start is establishing clear, evidence-based criteria and applying it consistently. 

Due diligence matters when creating privileging content

The Joint Commission requires privileging delineation to be an objective, evidence-based process. Beyond the key requirements of any accreditation or regulatory body relevant to your facility, privilege forms and criteria must reflect industry best practices and expert research. The following are guidelines for the research and development phases of creating privileging content for healthcare practitioners.

1. Know your regulations and standards

The best place to start when developing privileges is ensuring that you understand your accrediting body’s standards, in parallel with CMS and any state regulations if applicable (e.g., for APPs). For example, The Joint Commission Medical Staff Standards do not recommend any one specific privilege methodology over another, but state that the privilege must clearly and accurately define the specific activities/procedures/privileges to be included and reflect only activities/procedures/privileges performed at the organization. 

While licensure, training, and experience checks during privilege delineation are straightforward, there are many ways to gauge competence. Your bylaws, policies, and procedures documents are your starting point and the best defense for compliance, quality, and ultimately, patient safety. 

From there, take into consideration facility- and provider-level factors. Regulators require privileges must be individualized, meaning that any practitioner has the ability to opt in or out to a particular privilege with very few exceptions. Other considerations when tapping into industry standards on the individual facility level include relevance. Does my facility have the staff, resources, and equipment to include the privilege?

Researching and using industry standards requires upkeep to ensure that your privilege content reflects accreditors’ changes over time, just as you continuously monitor individual practitioners who have been granted privileges. 

2. Research multiple recognized sources 

Remember that the privileging content that you are researching will ultimately be presented to department heads and others for review. As a result, you’ll want to conduct thorough research. For its customers, symplr uses up to 40 resources when researching content for privileges in a specialty. Innovative sources include checking institutional review boards (IRBs) when seeking information about new equipment and technology. 

Tried and true methods include:

  • Going directly to the U.S. Food & Drug Administration to view a Summary of the Safety and Effectiveness of the device and to ensure there have not been any recalls or incidents
  • Seeking out industry recognized sources and specialty boards, specialty associations, and specialty organizations
  • Locating the appropriate experts by specialty
  • If a medical device is involved, contacting the device manufacturer

Whether or not you use core or cluster privileges, the Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association (AOA) provide the training and education necessary for any specialty that may be considered for the core privilege. When developing the privilege, it may seem like you’re building a laundry list at first. But documenting each and every procedure or service will help develop the core/cluster. 

Even if you outsource the information-gathering steps when creating or updating privileges, relying on one source is not enough. Use multiple, objective, evidenced-based resources to create a solid defense that you have done everything you can to appropriately set the bar for provider competence.

Conducting thorough research and tapping into multiple trusted, expert resources when data-gathering for core or special privilege reflects an effort to weigh different thresholds for the education, training, and volume criteria decided upon for your facility. It can also help avoid malpractice lawsuits, loss of accreditation, investigations, and negative media attention 

3. Seek in-house clinical input and approval

Accreditation bodies require facility clinical expert final approval. It’s also good practice to tap into your in-house expertise for developing specialty privileges. It’s appropriate to include the department chair and perhaps one or two additional practitioners. This strategy fulfills the goal of including varying opinions, yet the process won’t be delayed by trying to gain the consensus of a large group. The practitioners will feel invested in the qualifications and criteria, and the timeline for getting the privilege drafted and approved will remain on track.

As a result of the rise in endovascular and non-invasive procedures, many privileges apply to multiple specialties. On occasion, “turf issues” ensue, where one or more of the specialties disagree on what specialty types should be eligible to provide the care or service reflected in the privilege. Best practice in these instances is to create a multispecialty task force with representation from each involved specialty, and have the group report back to the Credentials Committee for a final determination as demographics may play a part in the decision as well.

4. Establish a policy for review of new technologies 

Medicine in the digital age means surgical interventions, devices, and treatments develop quickly and are brought to market at an unprecedented pace. Often, a new or expanded technology costs millions and brings the expectation of acutely needed new or increased revenue streams while maintaining the highest quality of patient care. Creating or revising privileges when an organization is presented with a new technology is particularly difficult for MSPs who are placed under pressure to quickly help determine whether to adopt it and/or what the resulting privilege will look like. 

Assuming that the new technology is FDA-approved, organizational-level due diligence must be conducted and the new technology, procedure or service will be offered by the facility, there’s still a great deal of work the Medical Staff Services Department in conjunction with medical staff leaders must do before the privilege is offered. 

If new privileges are required, many questions must be answered, such as:

  • Does the procedure, treatment, or service represent a direct extension of existing clinical skills or judgment?
  • Does the procedure carry a risk greater than existing conventional therapy?
  • What specialties will be eligible for the privilege. 

Finally, the privilege can be developed and the criteria recommended for approval. 

5. Consistently review privilege forms 

Sometimes the squeaky wheel gets the oil. Often high-profile or high-reimbursement departments or specialties consistently have their privilege forms reviewed and updated, while others remain stuck in the past. Or perhaps a lapsed review project has resulted in partial updates that reflect a privilege library with varying formats and styles from department to department. Both scenarios are symptomatic of an inconsistent review schedule.

Very few software programs contain privilege templates and a corporate privilege function to help streamline and standardize the main elements of the forms, so the necessary work can be done to customize by specialty and facility. Ideally, set a schedule to review forms every one to two years, working in collaboration with each department after you’ve researched any changes that might warrant a change to the form. 

Whether you “buy” or “build” your organization’s research and privilege templates, prepare to conduct the due diligence that will set your organization up for compliant privileging, quality, peer review, and patient safety.

Learn more about symplr’s enhanced privilege solution today that includes 257 specialties and +9,600 delineations using more than 30 sources, an ICD/CPT link to the provider’s privilege with the ability to link to OPPE for a privilege to procedure report, corporate privileging, criteria and content, and special threshold criteria that are editable.


Request a Demo