Credentialing & Privileging

Creating applications for privileging

[In the first two articles of this series, Vicki Searcy, president, consulting services at Morrisey Associates Inc. in Chicago, introduced the four basic components of clinical privileging as well as creating criteria for privileges:

1. Determine the scope of services that your organization will provide.

2. Determine the criteria (i.e, training, experience, behavior, skills) necessary to provide a specific service (or grouping of services) or procedures. Determine how to handle exceptions.

3. Allow applicants to apply for privileges and determine if they meet criteria. Make a decision and communicate it.

4. Monitor the individuals who are granted privileges to ensure their competence and practice within the scope of privileges granted.]

Here are some key components in making an application for privileges and determining if applicants meet the established criteria, according to Vicki Searcy, president, consulting services at Morrisey Associates Inc. in Chicago:

  • to think about how to provide applicants with privilege delineations (via paper or electronically);
  • to make sure that criteria for privileges are clearly communicated to those applicants.

Searcy says the best way to do this is to put the criteria for privileges on the privilege delineation itself "rather than separating the criteria into separate policies, rules and regulations, etc. (which often are not reviewed by applicants because they are in multiple documents). The principle here is to clearly make the criteria available so that applicants are aware of criteria and do not apply for privileges for which they do not meet qualifications."

She points to two different methods of displaying privileging criteria with the privileges (see figures 1 and 2, below).

Figure 1 - Privilege Cluster: Transplant Hematology Privileges

Description: Participate as part of a team in evaluation of patients with liver disease for potential hepatic transplant and evaluation of potential liver donors. Care and treatment of patients prior to and following hepatic transplantation that spans all phases of liver transplantation.


Request all privileges below.
Uncheck any privileges that you do not want to repeat.

Chief Approval

Dept. Chair Approval

Management of patient throughout hospitalization.

Procedures (This listing includes procedures typically performed by physicians in this specialty. Other procedures that are extensions of the same techniques and skills also may be performed.)

Performance and interpretation of percutaneous liver biopsies, including allograft and native


Completion of an ACGME accredited Fellowship training program in Transplant Hematology.

Certification: Current certification in Transplant Hematology by the American Board of Internal Medicine.

Clinical Experience
(#) patients treated during the previous 12 months AND (#) percutaneous liver biopsies performed

Completion of Fellowship training in transplant hematology during the previous 12 months

Clinical Experience

(#) patients treated during the previous 24 months AND (#) percutaneous liver biopsies performed
Additional Qualifications: Must qualify for and be granted primary privileges in gastroenterology.

〈 Three retrospective chart reviews chosen to represent a diversity of management challenges.

Source: Morrisey Consulting Services.

Figure 2 - Nurse Practitioner (partial delineation of privileges)

Privilege Description

Special Criteria for Privileges



Additional Education/Training Requirements

Clinical Activity Outcomes

Other Requirements and FPPE

Application of appliances and any other action delegated and directly supervised by the physician.

the American Association of Operating Room Nurses


Certification as an RNFA by the American Association of Operating Room Nurses


National Board of Surgical Technology and Surgical Assisting (NBSTSA) Certified First Assistant (CFA-ERC.)

2C - Line Insertion and/or Maintenance

Applicants for initial privileging and renewal of privileges must submit evidence of having performed each privilege requested in the past 24 months.

1 FPPE report is required for each privilege requested within 12 months of initial granting of privileges.

1. Arterial line insertion and maintenance.

2. PICC line insertion with image guidance and maintenance

All initial applications must provide documentation of completion of a program in ultrasound as applied to image guided procedures.

Source: Wendy R. Crimp, RN, MBA, CPHQ

"You'll note that on both privilege delineations, applicants are informed of FPPE/proctoring requirements, as well as education/training and outcomes criteria," Searcy says.

She says once someone applies for privileges, the medical staff office/credentialing department reviews the request and verifies the submitted information to ascertain whether the applicant meets criteria. "In the transplant hepatology example, the information to be verified would be completion of an ACGME fellowship in transplant hepatology, current certification in transplant hepatology by the ABIM [American Board of Internal Medicine], clinical activity requirements and whether or not the applicant has been granted privileges in gastroenterology."

She says this information should be gathered and confirmed before the application enters the evaluation and decision-making stage, which generally "consists of review by the applicable department chair, credentials committee, recommendation by the medical executive committee and board decision. When a department chair (and subsequent reviewers) receives a paper or electronic credentials file for review, all information should be complete and all required verifications should be available (i.e., verification of licensure, current professional liability insurance, etc.) for review. It should be clear to reviewers whether or not an applicant meets all criteria for the privileges requested."

Once a decision is made about the privilege, the applicant should be notified, along with any conditions, says Searcy, such as proctoring, supervision, consultation, etc. He or she should also be educated about organizational components that monitor "the exercise of privileges. For example, the surgery department should be able to look up the privileges granted to surgeons so that they know whether or not to schedule a specific case for a surgeon. If an allied health professional is granted privileges with supervision, patient care areas will need to know what supervision is required," Searcy says.

(Editor's note: In the next issue, we will examine monitoring competency.)